Mental Health Bill [HL]

Lord Alderdice Excerpts

2nd reading
Monday 25th November 2024 Lords Chamber

[Lord Alderdice (LD)]

My Lords, I am grateful for the opportunity to participate in this debate. I declare an interest as a retired psychiatrist and a fellow of the Royal College of Psychiatrists.

So much of what I will say comes from my experience of working as a consultant psychiatrist in Northern Ireland. This is particularly important because the legislation in Northern Ireland has always been different from the legislation on this side of the water. The 1950s’ legislation was referred to earlier. In Northern Ireland, the 1961 Act did not, for example, permit admission or detention on the basis of personality disorder. I will come to that in a minute because that foundational difference is of enormous importance.

I welcome this Bill, not because it is a perfect Bill and not even because the foundations of the Bill are particularly good, but because it is at least an improvement on the way things have been for some time. I welcome the four principles it identifies. There are choice and autonomy, a least restrictive approach, and therapeutic benefit—although, of course, this is a difficult one to assess in a short period, as the noble Lord, Lord Adebowale, has pointed out. It can be difficult to work out whether particular approaches to treatment are going to work in the short term. Often we need time. The fourth principle is treating the person as an individual, although again this is not as straightforward as it might appear.

As Dr Lade Smith, the president of the royal college, has pointed out, there are ways in which a piece of legislation such as this can be introduced. Although with plenty of resources there would be a good outcome, if there are inadequate resources the situation can be made much worse. It is not just that not enough resources do not make the situation sufficiently better; that can actually make it worse. For example, if a decision is made not to admit the most seriously ill patients to hospital, which is a very good principle, the consequence is that the people in the wards are even more disturbed and much more difficult to handle. Keeping the same level of staff makes it impossible to manage them because that number is not sufficient to deal with an increasingly toxic and non-therapeutic environment.

Changing from the most direct family member to a nominated person is very good. I entirely support it, but it is not without its consequences. If, before admission, the person is living with the family, but they decide to choose someone outside the family, the family may not be prepared to accept them back again. The nominated person may not be in a position to accept them either.

The truth is that none of us is simply an individual. We exist in the context of relationships. If we do not find ways of engaging with those relationships, simply operating on the basis of individual autonomy and human rights may actually create problems of its own. I absolutely agree that we should not admit disturbed people to police cells or to prisons, but if we do not provide sufficient alternative resources then either they are admitted to psychiatric units and other people who should be in those units are unable to be admitted because there is no room, or they are not admitted at all and things become worse.

This is a complex issue; it is not at all simple. There are unintended consequences. A whole list of colleagues have pointed this out: the noble Baronesses, Lady Murphy, Lady Hollins, Lady Buscombe and Lady May of Maidenhead, and the right reverend Prelate the Bishop of London. Almost anyone who has had direct engagement with the care of patients in these circumstances realises that there is a degree of complexity in dealing with them that a piece of legislation on its own will not resolve, especially if it is not legislation that requires the provision of resources—which, of course, this Bill does not. Doing something without resources can not only be unsuccessful; it can make the situation worse.

Are there better ways of dealing with this? Yes. The Northern Ireland legislation is much better. It is what was referred to earlier as fusion legislation. That is to say that it looks first at the question of whether a person has disturbance of mind and brain function and, secondly, at whether they understand the information relevant to decisions and appreciate the relevance of it. For example, a person who had delusional thinking would obviously not understand the relevance or appreciate it. It gets away from lots of the problems that this part of the country finds itself dealing with because of the separation of mental illness and mental capacity. Those two things were brought together in the Northern Ireland legislation. That was easier because, as I said earlier, personality disorder was never regarded as an appropriate basis for a formal admission in the first place.

As has been said by a number of colleagues, one of the difficulties that has to be dealt with when legislation is changed if that change is not fundamental—or, frankly, even if it is—is that the culture being operated in is one in which all the staff have been working for decades. Trying to change that is really difficult. One way of doing it is to take little steps. I regard separating out autism and learning disabilities as a positive step in the right direction. The noble Baroness, Lady Fox, is not in her place but I agree—perhaps unusually—with what she said about the overmedicalisation of problems of living. It is true in universities, where there are huge problems now in dealing with students. It is true in all sorts of areas. Every time someone has problems of living it is called mental illness: “I’ve got mental health, doctor”. We wish they did have mental health; that is what they do not have. That is why they have a problem.

All sorts of problems of living are now thought of as disturbance and disorder. That, in my view, is a serious mistake. I have to say that psychiatrists have made their own contribution to developing things in that way, but we have to pull back and look at it again. That is one of a number of very good reasons pointed out by noble Lords for why taking autism and learning disability out of that kind of package, and seeing them in a different way, is an important step in the right direction but—I come back to this again—as long as there is appropriate provision of resources. Without that, things will not go well and we will have unintended consequences.

Those who have produced this legislation and those who will scrutinise it have done and will do it with the best will in the world. They want to make things better and they are doing their best, but a funny thing happens in science: you produce a theory, do some work with it and then discover that it does not quite cover an issue, so you put in a little caveat. Then it does not cover that issue, so you put in another little caveat, and more and more. The whole thing becomes more complex until suddenly, one day, somebody says, “Do you know what? This is not the right theory”, and then there is a shift in understanding to a whole new way of thinking about it.

That is where we are with problems of this kind. We really need to make a paradigm shift. Your Lordships would expect me to say it but, on this issue, the approach that was taken where I was working in Northern Ireland is useful to explore, just as bringing together health and social care was useful. There are other useful things, such as advance choice, but there are so many that we could not possibly deal with them all in one debate. That is why we will be discussing them for quite some time.

Covid Contracts: Judicial Review

Lord Alderdice Excerpts

Monday 1st March 2021 Lords Chamber

[Lord Bethell (Con)]

That is a reasonable question, and, in fact, that was our starting point: the noble Lord will remember that, at the beginning of all of this, we supplied PPE to 252 NHS trusts and no one else—everyone else sorted out their own PPE. The reason we had to change was that this was a global crisis: borders were shut, factories closed down and every country in the world was desperate for PPE. There was no facility for a procurement manager at an NHS trust, let alone a small social care home in the West Country; those avenues were all shut. That is why it took a massive national effort to secure PPE. We now have a portal that supplies more than 50,000 different NHS and social care units; as I explained earlier, we have an enormous stockpile to secure that. This has been one of the big learnings of the pandemic: in order to have resilient supply chains, there needs to be some national muscle to make sure that it works properly.

[The Deputy Speaker (Lord Alderdice) (LD)]

My Lords, the time allowed for this Question has elapsed; I regret that we were not able to reach everyone on the list.

Covid-19 Update

Lord Alderdice Excerpts

Thursday 4th February 2021 Lords Chamber

[The Deputy Speaker (Lord Alderdice) (LD)]

I regret that we have not been able to call everyone on the list but we have now come to the end of the 30 minutes allocated to Back-Bench questions. I shall give a few seconds for Members and Ministers to change around before we continue.

Medicines and Medical Devices Bill

Lord Alderdice Excerpts

Report stage & Report stage (Hansard): House of Lords & Report: 1st sitting & Report: 1st sitting: House of Lords
Tuesday 12th January 2021 Lords Chamber

Amendment 13 agreed.

[The Deputy Speaker (Lord Alderdice) (LD)]

We now come to the group consisting of Amendment 14. I remind noble Lords that Members other than the mover and the Minister may speak only once and that short questions of elucidation are discouraged. Anyone wishing to press the amendment to a Division must make that clear in the debate.

Clause 3: Falsified medicines

Amendment 14

Moved by

--- Later in debate ---

[The Deputy Speaker (Lord Alderdice) (LD)]

We now come to the group consisting of Amendment 15. I remind noble Lords that Members other than the mover and the Minister may speak only once and that short questions of elucidation are discouraged. Anyone wishing to press this amendment to a Division must make that clear in debate.

Amendment 15

Moved by

Health Protection (Coronavirus) (Restrictions) (England) (No. 4) Regulations 2020

Lord Alderdice Excerpts

Wednesday 4th November 2020 Lords Chamber

[Lord Trevethin and Oaksey (CB) [V]]

My Lords, it is a pleasure to follow the noble Baroness. These regulations place everyone in the country under a form of qualified house arrest. The freedom to travel, to go into a friend’s house, to play sport, to go to the pub—all taken away. Lord Sumption was obviously right when he described this in his recent lecture as

“the most significant interference with personal freedom in the history of our country.”

Those who are the most affected are the young and active. The bill—billions and billions of pounds—is not an illusion. Who is going to pay that bill? Generally speaking, it will not be those who directly benefit from the lockdown. It will be paid by the economically active and the young, who for the most part are at no real risk, along with their children and perhaps their children’s children.

Is the Government’s decision a good one? I have no idea and I certainly do not envy the decision-takers. There are many unknowns. However, it seems that the country—in particular the young, who are being ordered to give up anything resembling a normal life when they themselves are not at risk—is entitled to expect certain things. The first is that decision is taken in a properly objective and rational way. There is an obvious danger in the so-called “sunk costs” fallacy which occurs when a decision to take a future course of action is justified by reference to costs already incurred rather than the merits and demerits of the possible alternatives. There is a particular danger of a sunk cost reasoning where the decision-taker is responsible for an earlier decision whose correctness may be called into question by a change of course. Is this fallacy operating here? It is troubling to hear one of the decision-takers say recently, “We have travelled too far to turn back now”. That is classic sunk costs reasoning.

Secondly, we are all entitled to expect that the adverse effects of the proposed course of action are evaluated as thoroughly as its beneficial effects. Where is that evaluation? We have heard a great deal about the deaths that will be avoided by the lockdown, but almost nothing from the Government about its effect on mental health, a subject on which the noble Baroness, Lady Meyer, spoke so powerfully, on the diagnosis of other serious diseases and on our future ability to be able to afford to care for those who fall ill.

Thirdly, we are entitled to expect that the evidence presented to us as justification for these very extreme measures has been assembled and considered in a properly objective way. Graphs, forecasts, projections and so on are guesses. The guesswork may be informed, but the utility of this spuriously precise-looking material depends entirely on the underlying assumptions. You tweak the assumptions and the figures on the bottom line jerk around wildly. Anyone who has dealt with forecasting in the commercial world knows that.

The already rather notorious 4,000-deaths-a-day graph deployed in terrorem at the weekend reminded me of a different claim about a different supposed weapon of mass destruction: chemical and biological weapons ready for use within 45 minutes of an order from Saddam Hussein—we all remember that one. That war against supposed WMD did not go well. This is a very nasty and dangerous virus but, if it proves that the cure is more damaging than the disease, we will have betrayed generations.

[The Deputy Speaker (Lord Alderdice) (LD)]

The noble Baroness, Lady Stroud, has withdrawn, so I call the noble Lord, Lord Boateng.

--- Later in debate ---

[Lord Barwell (Con)]

My Lords, I support the regulations, although it gives me no pleasure to do so. I concede that the lockdown will damage our economy and people’s mental health and will restrict our freedoms —all the arguments that my noble friend Lord Forsyth so eloquently spelled out. I do so because the lesson from the first wave is very clear: that the consequences of not acting are worse. The countries that took quick and decisive action did not see more damage to their economies and more people out of work; they saw less damage. Countries that, like us, were late to act did not better protect their economies; they saw a sharper fall in GDP and more job losses.

My noble friend Lord Robathan said that there was uncertainty about the sums. He is quite right, but at every stage during this process, we have suffered from optimism bias. Back in February and March, we believed that we were several weeks ahead of Italy, before it became apparent that that was not the case. We came out of lockdown in May and June too quickly, failing to achieve suppression of the virus—particularly in the north of the country, which is why the pandemic has recurred there first.

We did not listen to SAGE back in September, when its advice was for a short circuit-breaker lockdown. The Prime Minister clearly did not want to adopt the policy that he is now pursuing. We were told that this was all going to be over by Christmas. Even now, some noble Lords seem to believe that what is happening in Belgium, the Czech Republic and France will somehow not happen here.

I fear that we live in an age of increasing unreason, where experts are maligned. I have a lot of sympathy with those noble Lords who have asked to see the assumptions that underpin the modelling, but others go further. My noble friend Lady Noakes said that, although she could not comment on this herself, some have said that there is a deliberate plot to curtail our civil liberties. Who would benefit from such a plot? How can what the Government are recommending to the House possibly be in their interest? It will make their job over the next few years immeasurably more difficult.

I believe that a vaccine and improvements in treatment and testing are on the way. However, lest noble Lords fear that I am suffering from the optimism bias that I have criticised in others, let me say that, if we look around the world, there are countries that, even before those developments, have achieved suppression and returned life to normal.

As I come to the end of my time, I say to the Minister that the Government need to use this period to achieve proper suppression of the virus—to get the tracing system working properly and ensure better compliance—so that, if I am wrong in my optimism about vaccine treatment and testing, we do not find ourselves in January or February back debating a potential third lockdown. This measure is the right thing to do now to protect our NHS. It is better than any alternative course of action.

[The Deputy Speaker (Lord Alderdice) (LD)]

My Lords, the noble Lords, Lord McConnell of Glenscorrodale and Lord Greaves, have withdrawn so I call the noble Earl, Lord Clancarty.

[The Earl of Clancarty (CB)]

My Lords, my first question is: what is the Government’s understanding of where in the community the virus is being transmitted most? Surely this is the evidence that should be shaping the measures being taken, including this lockdown.

I welcome the Prime Minister’s intention to mass test. However, if, as the ONS has said, Covid is rising rapidly among older schoolchildren, should not a priority during this period be to test all schoolchildren and staff, and indeed university students and staff too? Will there be an advertising campaign to accompany the Liverpool testing pilot, perhaps along the lines of getting tested being a social duty, particularly as so many people might be infectious but display no symptoms? Mandatory testing, as in Slovakia, would create an undesirable precedent in the UK but Slovakia’s project to test the whole population over two weekends is nevertheless admirable.

On Friday, I was privileged to attend one of the few live performances of Sarah Kane’s play “Crave” at the Chichester Festival Theatre before it was live-streamed. Everyone was masked and socially distanced in an airy auditorium. Lockdown is another blow to the arts when they are just starting to get back on their feet, particularly because of their considerable dependence for survival on a paying public.

However, those who continue to be most affected are the self-employed. The increase in support, at least for the lockdown period, is welcome, but a majority of the self-employed in the arts and entertainment are ineligible for support. They include the newly self-employed and those paid through dividends. Freelancers who work in the arts will not be covered by the Culture Recovery Fund. In its report Jobs, Jobs, Jobs, the Resolution Foundation identified a real issue with targeting the self-employed most in need. Have the Government looked at that report? Will they address these continuing concerns?

Lastly, I ask the Minister for clarification on what the lockdown means for private music teaching. The Minister says that the Government are prioritising education. It is vital that this teaching continues through the lockdown to nurture the next generation of musicians. I sent the Minister a note on this question this morning, so he might not have had time to see it, but there is a discrepancy between the guidance and the legislation, which clearly lists education as an exception without specifying what form that may take. Can music teachers continue to teach privately from home and visit other houses to teach? Can private music schools still operate face-to-face teaching? Can peripatetic music lessons in schools take place?

Concerns about the status of extracurricular activity within Covid-safe environments extend to art, drama and sport, as we have heard, with huge implications for mental and physical well-being, which we should not neglect, even for a month.

[The Deputy Speaker (Lord Alderdice) (LD)]

The noble Lord, Lord Lamont of Lerwick, and the noble Baronesses, Lady Clark of Kilwinning and Lady Newlove, have withdrawn so I call the noble Baroness, Lady Smith of Newnham.

Covid-19: Local Restrictions

Lord Alderdice Excerpts

Friday 9th October 2020 Lords Chamber

[Lord Bethell (Con)]

I completely defer to the noble Baroness’s expertise in matters to do with the devolved Administrations, but I reassure her that there are numerous calls every day between Whitehall and the DAs on Covid. We very much celebrate the achievement of a four-nations approach. There are divergences in some procedural matters between the different countries; that is entirely to be expected—indeed, celebrated—as it enhances the effectiveness of our measures. But I completely take on board the noble Baroness’s points and we will endeavour to ensure that communication between Whitehall and the DAs remains firm and solid.

[The Deputy Speaker (Lord Alderdice) (LD)]

The noble Lord, Lord Mann, has withdrawn, so I call the next speaker, the noble Viscount, Lord Waverley.

[Viscount Waverley (CB) [V]]

My Lords, the issue is indeed about collaboration with local government. However, the Government’s decision to introduce the Coronavirus Act marred the use of secondary legislation in respect of the Civil Contingencies Act, suggesting that the Executive believe that existing legislation is not robust enough to counter the threat of pandemics. Given that we live in such a world, what plans do HMG have to review the robustness of all existing legislation? If they do, can they confirm that it will not infringe on parliamentary sovereignty?

--- Later in debate ---

[Lord Bethell (Con)]

I reassure the noble Lord that we are making progress. He is entirely right: the ventilator challenge is an inspiration, and I note that we have hit our target of 30,000 ventilators. I note that we have 300,000 tests a day at the current run rate; we have re-registered 50,000 new clinicians to return to support the NHS; we have had 16 million downloads of the NHS app; we have recruited 14,200 nurses as part of our recent recruitment; we have processed over 24 million tests in laboratories as of 8 October 2020; and the Vaccine Taskforce has secured access to six different vaccine candidates across four different vaccine prototypes. These are enormous achievements and we will continue to pursue our response with energy and vigour.

[The Deputy Speaker (Lord Alderdice) (LD)]

My Lords, the time allowed for this Private Notice Question has elapsed. I regret that we have not been able to hear all the speakers.

Health Protection (Coronavirus, Collection of Contact Details etc and Related Requirements) Regulations 2020

Lord Alderdice Excerpts

Wednesday 7th October 2020 Lords Chamber

[Baroness McIntosh of Pickering (Con) [V]]

My Lords, I thank my noble friend for bringing these regulations forward today and, in particular, for his admission that it would help to publish such regulations before they are laid. That would be very welcome. They should also be brought to Parliament before they are implemented in future. Those two developments would help the industry and both Houses to scrutinise them.

My noble friend is under no illusion about how great the impact of Covid has been on the hospitality sector, which reopened late in the day, only in July. I find the application of these regulations particularly helpful, as they appear to help hospitality facilities, which are their target, to remain open. The announcement over lunchtime today that Greene King may close a number of establishments, some permanently, with a mass loss of jobs, is deeply worrying and possibly the tip of an iceberg.

I will ask one question and make one comment and proposal. Could my noble friend clarify the level of fine for a first offence? It seems reasonable for £500 to be the top level for a first offence, because there could be a difficulty in understanding and adhering to the rules. An increased fine for a second or third offence would seem reasonable. However, one part of the regulations before us today says that £500 will be the first fine; in another place, I see £1,000. I make a plea for £500, which seems more reasonable.

It is not the work of his department, but my noble friend is aware of this and I have raised it in connection with other regulations. Since Covid-19 became so extensive, water companies have been regularly testing wastewater at both household and community levels. It is then sent off for analysis by the Environment Agency. The thrust of debate on these regulations, the previous Urgent Question and all comments generally is that we need lockdowns that are as localised and short as possible. The benefit of testing wastewater is that, while it cannot be limited to individual households, it can be limited to a narrow community. Could my noble friend see whether his department can liaise with the Environment Agency and Defra to see whether the information gathered could be used to target more specific, community-based, smaller lockdowns, which would last for shorter periods? That would help both the local community and the hospitality industry, which has taken the brunt of the regulations, such as those before us today.

[The Deputy Speaker (Lord Alderdice) (LD)]

We ran into some technical problems earlier, so I propose to try again to hear the last two questions of the noble Lord, Lord Naseby.

Social Care

Lord Alderdice Excerpts

Wednesday 8th July 2020 Lords Chamber

[Lord Bethell]

The noble Baroness is quite right to allude to the very large number of White Papers, think tank reports and amount of documentation in this area. All I can say is that I have never seen such acute political will and focus on social care reform. Nor have I seen a Prime Minister, a Secretary of State and a chief executive of the National Health Service to be so focused on the matter and to have raised it as a major priority in all their communications.

[The Deputy Speaker (Lord Alderdice) (LD)]

My Lords, the time allowed for this Question has elapsed.

Personal Protective Equipment

Lord Alderdice Excerpts

Wednesday 24th June 2020 Lords Chamber

[Lord Bethell [V]]

The noble Baroness is entirely right to emphasise the disproportionate balance of infection among BAME people and the importance of interpreters in ensuring that they get the treatment they deserve. However, we are emphasising the use of telephone services because we want to keep people out of areas of potential infection. That remains part of the service that we deliver, and telephone arrangements are proving extremely effective. However, I take on board her point about providing PPE for those interpreters who are on site, and I will continue to press those in the department who oversee this important area of activity.

[The Deputy Speaker (Lord Alderdice) (LD)]

My Lords, the time allowed for this Question has elapsed and we come now to the third Oral Question, from the noble Lord, Lord Wallace of Saltaire.

Coronavirus Bill

Lord Alderdice Excerpts

2nd reading & 2nd reading (Hansard) & 2nd reading (Hansard): House of Lords
Tuesday 24th March 2020 Lords Chamber

[Lord Alderdice (LD)]

My Lords, I direct the House to my medical and research interests noted in the register. The Minister, in his excellent introduction to the debate, referred to the lessons from the 1914-18 war. I understand that reference and have some sympathy for it. However, my friend the anthropologist Scott Atran has pointed out that there are certain dangers in using the terminology of war, because it tends to turn people towards various “isms”: racism, chauvinism, ethnocentrism and xenophobic nationalism—exactly the opposite of the things that we want to find in our global community at the moment.

In truth, a more accurate reflection would be to address the lessons of the 1918-20 flu pandemic, which crossed the world and led to the deaths of tens of millions of people. However, two things about that experience are different from our own. One is that people experienced it immediately after the war, when tens of millions of people had died. To some extent, they were emotionally almost numbed by the whole business of massive death. Secondly, unlike us, who are used to antibiotics, vaccination and an expectation that people will not die of infections, people at that time were very much aware that people died of infections, sometimes in large numbers.

These facts contribute to what another colleague of mine, Dr Kerry Sulkowicz, the president-elect of the American Psychoanalytic Association, has referred to as the second pandemic of the moment, which was referred to by the noble Lord, Lord Blunkett, and other noble Lords: a pandemic of anxiety. It is not that he suggests that this is an inappropriate or pathological anxiety. On the contrary, it is a very realistic anxiety, because what is ahead of us is profoundly dangerous and challenging. We do not even know how dangerous and challenging, so anxiety is not an unreasonable response; it is a natural, human response. However, it produces problems in reaction. It leads some people to be so overwhelmed that they deny the reality. Even coming through London today in my car, not by public transport for safety reasons, I still noted groups of people out on the street in much more than twos and threes, not taking seriously the very sensible advice that they have been given publicly by the Prime Minister, Ministers and other experts.

Sometimes it leads to people being paralysed by the anxiety so that they do not know how to deal with things, but it also often causes illness—not just psychiatric and emotional illnesses of various kinds, but physical illnesses. Many people will be falling ill, physically and mentally, as a result not of the coronavirus directly, but of the psychological sequelae of it. There are many sequelae, not just anxiety. Reflect, for example, on what it will mean for many people, particularly older people on their own, to face three months or more without ever having touched a person or been touched by them. As human beings, the physical dimension of life is of enormous importance. They will be losing that and undoubtedly reacting in ways we do not know, because it has never happened in this wise before.

Many years ago, I was called to do work at a hospice where the staff were finding difficulty in continuing their work. It became apparent that this was because of the repeated, incessant, unremitting experience of the deaths of those they were working with. Reflect for a second on what it will mean for health service staff, who have been relatively well used to getting people better, to find that hundreds and hundreds of their patients will die. How will they manage, psychologically as well as physically? Can the Minister say how much thought has been given to addressing these problems?

There are many other things that I could mention but I will say two. One is that there are, in the voluntary, private and community sectors, employee assistance programmes that have been relieving the health service of having to deal with many of these problems. They are not going to be able to survive financially if there is no assistance for them. The noble Baroness, Lady Hollins, who is not in her place, has asked that we also remember the problems, as have been mentioned, for those who are vulnerable because of learning disability. Finally, because there will be more people admitted on formal orders, can we monitor how many more patients come in than would normally be the case on such orders, so that we have a sense of the increased burden on the psychiatric services?