Mental Health Bill [HL]

Lord Crisp Excerpts

Committee stage
Wednesday 22nd January 2025 Lords Chamber

[Lord Crisp (CB)]

My Lords, I will speak to Amendment 148, which is in my name and that of my noble friend Lady Hollins. I also support all the amendments in this group. Indeed, on the ones introduced by the noble Earl, Lord Howe, I very much support the stories that we have heard and which he spoke about at Second Reading. I also note the points made by the noble Baroness, Lady Tyler, about non-drug therapies, which relate very much to what I will talk about.

I will make one general point: a generational change in the whole field of mental health is happening globally, with a shift towards more social interventions and preventions. This wider context needs to be recognised a bit more in the Bill. Amendment 148, which is about withdrawal from dependency-building drugs, is part of that context. I also agree very much with the point that the noble Baroness, Lady Tyler, just made that drugs are needed, and with the powerful points raised by the noble Baroness, Lady Fox, in the last day in Committee on the real pressures and problems that people within the NHS and beyond face in working with some of the people they end up having to work with, and on the conditions that they are working in. This emphasis on social interventions, therefore, is not at the expense of other aspects of mental health.

Some of these interventions do harm. I will come on to the point about withdrawing from drugs. On reducing prescribing and supporting withdrawal, I do not understand why this Government, through the Bill or otherwise, are not making changes that could help to reduce costs and improve services, which would take pressure off all services and, indeed, improve people’s economic position by enabling them to be fit to work.

Mental Health Bill [HL]

Lord Crisp Excerpts

Tuesday 14th January 2025 Lords Chamber

[Lord Scriven (LD)]

My Lords, I will speak to Amendments 22, 24, 25, 26, 29, 30 and 31 in my name in this group. I support Amendment 28, which was just spoken to very ably by the noble Baroness, Lady Browning, and Amendments 36 and 37, in the name of the noble Baroness, Lady Hollins. I want to put on record my condolences to her at what must be a very sad and difficult time.

Quite a number of amendments that I have put down in this group, particularly Amendment 22, are about prevention. It is about getting upstream and trying to use the dynamic support registers—the risk registers—in a better way, and, by so doing, having the correct information that is available to a place, rather than just to an organisation, such as the NHS or the ICB, within that place.

Amendment 22 would ensure that local authorities have an active role in assisting ICBs in identifying people for inclusion in the risk registers. NHS England’s policy and guidance on dynamic support registers states:

“Early identification of people at risk of admission to a mental health hospital and their access to person-centred planning and support are essential for the prevention of avoidable admissions”.


Many people with risk factors will first come into contact with a local authority, particularly people with learning disabilities and autism. It is important that the local authority has a clear responsibility to assist ICBs in identifying people for inclusion on the register, to ensure that people get the right support at the right time. I hope that the Minister will take this amendment in the spirit that it is given. This is an important issue which is not strong enough in the Bill and which really needs to be taken account of.

There have been difficulties for some people getting enrolled on the DSR, and this is particularly true for autistic people without a learning disability. Additionally, NHS England data shows that 52% of autistic people and people with a learning disability detained in a mental health hospital are not on a risk register prior to admission. Therefore, there is a gap, and the Bill gives us a chance to help plug it. Hopefully, placing this duty on local authorities will facilitate greater uptake and enrolment on the register for all, therefore helping to reduce admissions, improving support in the community and being a good preventive measure.

Coupled with this, Amendments 36 and 37 in the name of the noble Baroness, Lady Hollins, would help with that prevention role by making sure that proper provision was available. Taken together, Amendments 22, 36 and 37 would be a really good group of steps forward to help with preventive measures to make sure that all people who can be identified who come into contact with a local authority but are not known to the ICB go on the register, and that provision is made.

Amendments 24 and 29 would change the current language in the Bill. After listening to debate on previous amendments, I will not labour the point because I have a good idea what the Minister might say, but again I think the provision needs to be strengthened so that ICBs and local authorities have a duty to consider the risk register when exercising commissioning and marketing functions.

In Amendments 25 and 30 there is the same approach by strengthening the words in the Bill to ensure that ICBs and local authorities have a duty to ensure that the needs of autistic people and people with a learning disability are met in the community wherever possible. The current language in the Bill states only that ICBs and local authorities must “seek to ensure” that the needs of autistic people and people with a learning disability are met. This wording is vague and does not compel a strong enough duty to meet the needs of people in the community. Again, the amendments in the name of the noble Baroness, Lady Hollins, would strengthen my amendments even further.

These amendments are important. I hope that the Minister has listened very carefully, will make efforts to implement some of these steps and reports back on Report.

[Lord Crisp (CB)]

My Lords, I will speak to my noble friend Lady Hollins’s Amendments 36 and 37. I add myself to the comments by the noble Baroness, Lady Watkins, about the remarkable commitment that my noble friend is showing at this awful time and express my personal condolences. What I am going to say is based on comments that she has passed to me. I should perhaps say at the beginning that I too am an honorary fellow of the Royal College of Psychiatrists—“(unqualified)”, as others have made that disclaimer.

The purpose of these amendments is very clear. Amendment 36 states that ICBs

“must ensure the availability of integrated comprehensive, accessible, and responsive community services for autistic people and people with learning disabilities … to reduce hospital admissions … and … reliance on restrictive interventions”.

As the previous two noble Lords said, it is very much about prevention and creating appropriate services.

I note that the Explanatory Notes to the Bill say that Clause 4

“is designed to help ensure that ICBs can monitor individuals at risk of detention and put in place the necessary preventative measures to help keep people out of hospitals”.

Putting it simply, this amendment takes that rather weak wording in the explanation and toughens it up. The issue here is not about good intentions and ensuring that it is possible for something to happen. I am sure that all noble Lords share the intention and the hope that these things will be in place, but this is about making sure that something happens. It is about implementation and seeing that a change happens.

This is vital because it is clear that there are major problems in service coverage right now. For example, only a quarter of integrated care systems are meeting their target of having only 30 people per million admitted. Of course, that number would ideally be much lower than it is, but only a quarter of these systems are even meeting that. Amendment 36 spells out what these services should include. I will not read them out in detail but noble Lords can see that they cover all the relevant areas that one would expect: evidence-based treatments, crisis prevention and intervention services, non-restrictive walk-in services, and the provision of “suitable housing”.

I will comment on two of those items in a moment. All of them are important but what I think the noble Baroness, Lady Hollins, had in mind was not just discussing these items but seeing her amendment as an opportunity to discuss which services are the right ones—the ones that should be there—and which areas ICBs and local authorities should address. The key point at this stage is not so much about the detail but the need for some clear legislative requirements on what services must be provided. Good intentions are simply not good enough; implementation is what is needed.

I will mention two of those items that relate to points made earlier by other noble Lords in our debates on this group and others. One is the reference to “non-drug-based interventions” and “social prescribing”; their importance in community services applies in all kinds of ways. The second is the point about housing, which, as has been discussed, is vital. Ten years ago, I did a review for the Royal College of Psychiatrists on discharges from acute adult hospitals. A third of the people in those hospitals were there because they did not have adequate accommodation anywhere else. That third included people who had nowhere to be discharged to, in terms of adequate housing. It is a really serious issue. I make those points because both of these issues go beyond this amendment: in some ways, they are not about healthcare as much as they are about enabling people to have a decent life and creating the conditions for people to be healthy and live in the best way possible.

Amendment 37 is about issuing guidance on standards and monitoring and reviewing progress. Again, without that, we cannot be sure that this legislation will make a difference to the people who matter.

I will make three final points. I recognise that there are perverse issues of finance here because, of course, the NHS pays when people are in hospital and the local authority pays for the services in the community. Of course, that reminds us all of the need to get the social care policy right and the importance, wherever the boundaries fall between public bodies, of using public money wisely across organisations.

In that context, I stress that what the noble Baroness, Lady Hollins, has set out in this amendment is not an unachievable wish list. Even in today’s circumstances, some people are making real progress. Mencap pointed me towards the Black Country’s emergency response team, which noble Lords may know about and which meets many of these criteria for services. In 2022-23, it supported 51 people who were presumably being paid for by the local authority and who might otherwise have been admitted for the equivalent cost of a single assessment and treatment bed, presumably paid for by the NHS. Preventive and good-quality services so often make good financial sense, as well as being better for the people concerned. I do not know whether the Minister is familiar with that project but I would certainly encourage her to have a look at it if she has not already done so.

The second point I want to make is that, although I have not actually checked the reference, I believe that the Minister said something at Second Reading about delaying the implementation of some parts of this Bill until the services are in place. I would be grateful if she could say what was meant by that, but also why it is necessary when people can make progress quite quickly.

The Black Country example—and I suspect that there are others—shows that people are making progress and that, in many ways, it is better to have a stretching target that people are moving towards rather than saying, “If you don’t have the services, we won’t implement the legislation”. We need to keep moving forward and show faith both in what this Bill is designed to achieve and in the Government’s agenda on prevention and on moving towards the community. No doubt the digital transformation is also extremely relevant here.

Anti-depressants: Cost, Risks and Ramifications

Lord Crisp Excerpts

Wednesday 11th December 2024 Lords Chamber

[Baroness Merron (Lab)]

I am not specifically aware, but I will be glad to look into this.

[Lord Crisp (CB)]

My Lords, I want to raise the issue of dependency on anti-depressants. As the Minister will know, a lot of people have great difficulty coming off these anti-depressants. It is striking that for those using drugs illegally or with substance abuse, there are many services, but there are no services in the NHS for those seeking to withdraw from anti-depressants. This is a major problem. With that in mind, I ask two questions. First, will the Government consider the delivery of a helpline, which has been called for in a number of reviews, so that people can have some access to help? Secondly, will they support an NHS project designed to introduce withdrawal services within the NHS?

[Baroness Merron (Lab)]

The noble Lord makes an important point about the effects of withdrawal from any medication. I am not sure that this is an exact answer but there is the 111 helpline, which has been expanded to refer to mental health services, so people can ring and ask those questions. However, I take his point about withdrawal. We may wish to consider this as we go towards the 10-year plan.

Mental Health Bill [HL]

Lord Crisp Excerpts

2nd reading
Monday 25th November 2024 Lords Chamber

[Lord Crisp (CB)]

My Lords, I too welcome the Bill. It is overdue and times have changed. People’s views and sentiments, and our knowledge, have changed over those years. I welcome the principles that seek to rebalance the way we handle these issues.

All this is in the context of a Bill that is about the safety of service users as well as public safety. I want to come back to the former but, very briefly, on public safety, I note that the bar for detention will be higher—there must be evidence that

“serious harm may be caused to the health or safety of the patient or of another person”.

The question is: what counts as evidence? Where is the place for the judgment of experienced clinicians? Is that evidence? Is the testimony of relatives? What is the definition of “serious harm?” I understand the need for transparency, but this is a very difficult area that will obviously need much more discussion at later stages of the Bill.

I also welcome the separation out of the care for people with learning disabilities and autistic people, the attention to the needs of people in the criminal justice system and, of course, the importance of tackling racial disparities.

We have had a lot of impressive briefings for this Bill. I will quote one of them, from Blooming Change. That was the one about children who had experience of the system. There were lots of issues about patient safety and quality of care. They talked about being injured during restraint, just being drugged and restrained and being scared all the time. There is a dreadful sentence there, which I will read out:

“Hospital makes you worse … going into hospital with one problem and then leaving with trauma, new behaviours, new diagnoses, assaults, PTSD – it’s awful”.


I noted the earlier comments by the noble Earl, Lord Howe, about the very large number—I think it was 52,000—of uses of restrictive interventions in the last year, and the comments of the noble Baroness, Lady Watkins, about this, and about the importance of children not being in adult wards. It seems to me that this is a great example of what we just heard from the noble Lord, Lord Alderdice, about admission making the situation worse. The idea was to put people into a ward, but, actually, it led to a deterioration of their condition.

If I think about the Mental Health Act, I understand why the review that a lot of this was based on was focused, but actually we cannot think about the Mental Health Act in a vacuum. Let me pick up two or three examples of that. The first one is that the very same Sir Simon Wessely asked me 10 years ago to look at the capacity of acute adult wards across England. I did so, and with a group we were in contact with every service in England and with consultants who were leading the admission and discharge of patients. One of the interesting findings of that was that something over 20% on average of discharges were delayed because of housing. Indeed, of all those units in England, only two had any links with the housing authorities. This seems to me to be a very fundamental point: if you are stuck in hospital, you may well lose your accommodation, which will lead to other problems. That is just one example of many wider social issues that need to be taken into account, even though we are focusing on something as narrow as the terms of the Mental Health Act.

There is also the impact on A&E, which the noble Baroness, Lady Barker, and the noble Earl, Lord Howe, referred to very early on about just shifting the problem if we are not careful: shifting it from one place to actually landing up in A&E, where there may not be liaison, psychiatry or anything else that will help with the problem.

A number of noble Lords deplored the lack of a wider Bill in which this would nest, but it is very clear that this needs to be implemented in the context alongside other changes that are already under way. There are some profound questions here about care and treatment. We have been very privileged to have heard from a lot of people who know a great deal about this, including a number of very distinguished senior commissioners who could give us insight, as well as parents who can give us remarkable insight and profound comments.

If you look at some of the statistics, healthy life expectancy for all of us has improved massively over the last 40 years, but the gap between life expectancy for those with severe mental illnesses and life expectancy for the rest of us has doubled since the 1980s and is now 20 years behind. If we also look at some other evidence, the NHS independent Mental Health Taskforce argues that outcomes from severe mental health problems have worsened in recent years, and others have argued that they flatlined for about 40 years and, in some cases, have deteriorated.

Various noble Lords have talked about the importance of the change in the model that we are talking about here, with much more focus on the community, much more focus on prevention and much more focus on thinking of this end to end, rather than just as isolated incidents involving isolated patients who do not have relationships with the rest of the world in that sort of model. It really seems to be fundamental that we get hold of those issues; even if they are not in this Bill, they need to be linked to an understanding that those changes may well come with the forthcoming 10-year plan and the implementation of this.

I want to touch on a wider point about the overmedicalisation of common problems. Here is another statistic: in the year to April, 8.7 million people received antidepression tablets—and that is just England, without counting anywhere else. The major problem in that area, apart from the overprescribing itself, is helping people to get off those drugs in due course, which is another example of where some of our current practices have been doing harm. We need a new emphasis on some of the social interventions that many noble Lords have mentioned and a new emphasis on patient safety.

Lastly, this is only legislation. It needs to be accompanied by a real implementation plan for the management of change because it cannot be treated in isolation. These other moves and other leaders are making change happen elsewhere. I very much welcome the Bill and look forward to the discussions about some of these important issues in Committee and beyond.

NHS Continuing Healthcare

Lord Crisp Excerpts

Monday 2nd September 2024 Lords Chamber

Asked by

[Lord Crisp]

To ask His Majesty’s Government what assessment they have made of the effectiveness of NHS Continuing Healthcare in supporting people with long-term complex health needs living in their own homes or in community facilities.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)]

NHS continuing healthcare fulfils a unique function within the health and social care system, providing support for people with the highest levels of need by fully funding their health and social care. To monitor its effectiveness, the department works closely with NHS England, the wider sector, such as the Parliamentary and Health Service Ombudsman, and voluntary organisations which represent people with lived experience. This includes assurance work and projects to promote consistency in implementing this care.

[Lord Crisp (CB)]

My Lords, I thank the Minister for her very positive response. As she says, NHS continuing healthcare is vital. However, there are problems. Some of those are about finance, but I want to ask her specifically about the criteria for eligibility both nationally and locally, which are obscure and difficult. First, at the national level, can the Minister define precisely the level of nursing or other health services that a local authority can legally provide and which therefore do not have to be provided by the NHS? Secondly, almost 85% of applications other than fast track are refused, yet people have been encouraged to apply by health and care workers locally. Does the Minister agree that more needs to be done to ensure there is a clear understanding of who may or may not be eligible, rather than wasting so much of patients’, relatives’ and professionals’ time on unsuccessful applications?

[Baroness Merron (Lab)]

I do understand the concerns raised by the noble Lord and agree that we need to take a close look at all these areas. I have already raised that with officials and with Minister Kinnock, who is the responsible Minister in this area. On the second question, there is indeed a relatively low conversion rate, and I understand that the decision was originally made to ensure that everyone who might be eligible is actually assessed. The assessment acts as a gateway to other NHS-funded care but, having looked at it, this could perhaps be made somewhat clearer. On the first question, the noble Lord will understand that I cannot give a definitive answer, and he will be aware that legislation does not limit the number of hours or the cost of nursing care that a local authority may provide. However, the Care Act 2014 sets out that local authorities can provide nursing care only in very limited circumstances—for example, where it is a minor part of overall care, such as basic wound care.