First-cousin Marriage

Lord Kamall Excerpts

Monday 20th January 2025 Lords Chamber

[Baroness Merron (Lab)]

I certainly have not, and I am not aware of discussions that have taken place between Ministers or officials in our department and those in other countries. However, I will be very glad to look into that and to write to the noble Baroness.

[Lord Kamall (Con)]

My Lords, I thank my noble friend Lord Farmer for the Question, and the Minister for the sensitive way in which she is handling it. When we want to look at policy in sensitive areas, surely, we should be led by the data, so I just wonder what the Government’s latest data is. We know that about a decade ago, 6% of congenital defects or anomalies were in children born to first cousins in Pakistani communities, compared to 3% for the wider population. I have seen more recent statistics that say the figures are now 4% and 2%. So, what is the latest data the Government are working with, and what level would those congenital defects have to reach before they were seriously concerned?

[Baroness Merron (Lab)]

I thank the noble Lord for his support in this area, which is indeed sensitive. The statistics he quotes are quite right. It is of course an interesting reflection that the risk of genetic abnormalities does not just double from 3% to 6% in those infants whose parents are first cousins, but also doubles in older white British mothers—I am a bit worried about saying “older” because it is actually over 34. However, the point is well made that it is not just this group. NHS England has recently published guidance to improve the recording of national data on closely related couples, so I hope that noble Lords will find this of interest as we go along. But of course, there has also been much investment in research as well as data development, and I absolutely agree that data is what has to drive us.

Mental Health Bill [HL]

Lord Kamall Excerpts

Committee stage
Monday 20th January 2025 Lords Chamber

[Baroness Parminter (LD)]

My Lords, I want to say a few things about a couple of the amendments. I thank noble Lords for listening and for recognising the situation. It was powerful to hear that, and I am sure that many in the eating disorder community will be delighted to hear it.

I will not repeat what I said at Second Reading, as there seems no need, but in mentioning that, I want to support the amendment tabled by the noble Baroness, Lady Browning, which picks out the focus on community care and the need for more psychiatrists. I and others have made the case for why CTOs can be valuable for people with eating disorders—and for forensic patients, I understand. The value of the CTO is that the individual is helped to engage in the community with their mental health team. It is a multidisciplinary team, but the anchor is the psychiatrist. The noble Baroness was not sure if this was the right place to put her amendment because it has wider ramifications, but it certainly has value in this debate. CTOs, which I believe should be retained, can work only if there are proper multi-disciplinary teams anchored by a psychiatrist in the community, so that those individuals can be kept out of detained settings and engaged in the community. I thank her for bringing that forward, and I support it.

With regard to Amendment 44, I do not support a maximum duration for a community treatment order, because this is about the individual and what they decide, with their multidisciplinary team. What I like about the amendment tabled by the noble Lord, Lord Scriven, is that it rightly says that we have to review community treatment orders. People’s mental health situations change, and it is important to have step points at which people know they will be reviewed. I do not support a maximum time limit but the break points, which his probing amendment talks about, are worthy of further debate and discussion. I am grateful to him for bringing that forward.

I say with regret that I do not agree so much with the support of the noble Baroness, Lady Bennett, for retaining the automatic referral to a tribunal of any CTO that is lifted. Again, that goes against my sense that CTOs are about what is right for the individual. With eating disorders, there will be cases of CTOs being lifted because the person is no longer able to engage with the community team because the eating order has gone beyond the bounds of the CTO and is compromising their health and putting them, bluntly, at risk of death. I do not see why, in those circumstances, there needs to be an automatic referral to a tribunal. Strengthening people’s rights to go to a tribunal where there is a case for that is right and proper, but, because of my view about personalised care—especially for eating disorders, but this has wider ramifications—I do not support the case for automatic referral.

I know that there are people around the Committee who understand the concerns far better than me, particularly about the high preponderance of people in the black community who are on CTOs. I understand and hear that concern. I tried to get to the bottom of the figures, like the noble Baroness, Lady Bennett, to find out how many forensic patients were on CTOs. Given that you are four times more likely to be in prison if you are a black person than a white person, I tried to work out what the figures were to get the correlation to say whether it is because there are more people in prison that CTOs are preponderantly in the black community. I could not work that out. Equally, I could not work out how many people with eating disorders were on CTOs. I got the Library to try to help me, and it said that the figures are not cut that way and do not work that way. It seems to me that there is an issue about the data that we, and the Minister, are working with to make informed decisions.

I am not sure about the exact terms and conditions of the review that has been proposed by the noble Lord, Lord Kamall, and which in a later group is proposed by the noble Baroness, Lady Tyler, but I think there is an issue about the data out there. It is not helping us, or anyone else, make CTOs work for those where they can work, are working and should work in the future, and is clearly causing a problem. We need to get to the bottom of that.

[Lord Kamall (Con)]

My Lords, I thank all noble Lords who have spoken on this group. I will speak to Amendment 66 in my name and that of my noble friend Lord Howe. One of the motivations when we were considering amendments from our Benches was not only to respond to concerns raised by stakeholders but to probe the Government on why they did not accept some of the recommendations of the pre-legislative Joint Committee. That is the nature of these amendments. To the noble Baroness, Lady Fox, I say that the amendment is meant as a probing amendment to ask the Government why they have not adopted all the recommendations of the Joint Committee.

One of the things that drives many of us—I feel particularly strongly about this, given my background—is why so many people of an Afro-Caribbean background are being detained or are subject to CTOs. The noble Baroness, Lady Parminter, made a valuable point. One of the reasons I have tabled other amendments along those lines, which will be discussed in later groups, is that, after all these years of saying that too many people from the black community are being detained, if we want to do something about it, we need data, and we need to understand why they are being detained. Without the data, it is left to rumour or speculation, or people make up reasons. Everything needs to be driven by the data if we are to address the fact that a disproportionate number of black people are detained.

We tabled Amendment 66 because the pre-legislative committee recommended that community treatment orders be abolished for Part II patients, those not in the criminal justice system, and wanted a statutory process and timeline to be put in place for the review and potential abolition—I say those words from the Joint Committee’s recommendation very carefully—for Part III patients, those involved with the criminal justice system.

Many noble Lords came to the Second Reading debate wanting to see an end to community treatment orders, and many noble Lords have spoken tonight about this. We were all struck by the words of the noble Baroness, Lady Parminter, and of the noble Baroness, Lady Barker, who very honestly said that, having listened to patients and families, she knows that there is a small group of people for whom CTOs work, are the least restrictive option and are beneficial, and we should therefore keep them. I was particularly struck by that. The noble Baroness, Lady Fox, said that people do not change their mind very often, but the views that we brought to the debate in the first place have been challenged.

The noble Baroness, Lady Barker, made the important point that, while she is reluctant to admit it, she believes that there should be a change in the process around CTOs. That is important. This is why this probing amendment is asking for a comprehensive review of CTOs. We have listed a number of criteria that should be in that review, but I know that many noble Lords have concerns over CTOs.

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[Baroness Merron (Lab)]

I can understand the frustration that the noble Baroness outlines. It is hard for me to comment on a number of those 20 years. My feeling is that that is why we are here today updating the Bill. Indeed, at the risk of repeating myself—I will try not to—I take the point that she is making, yet I feel there is a need, under the updated Bill, which I hope will become an Act, to review the overall impact of the new provisions. I understand that we cannot be on a hope and a wing and a prayer. That is not the intention. We will keep CTOs under review as we implement changes. I certainly want to keep a very close eye on their impact, as I know your Lordships’ House will. I know that noble Lords will not be shy to raise any concerns that they have.

Amendment 66, in the name of the noble Lord, Lord Kamall, and supported by the noble Earl, Lord Howe, would require the use of community treatment orders to be reviewed within two years of the Act being passed. As a number of noble Lords have said, we believe that CTOs can be valuable for certain patients—indeed, as we have referred to, the noble Baroness, Lady Parminter, spoke about their benefit for eating disorder patients, as she did at Second Reading—but reform is needed so that they are used only when appropriate and for the shortest possible time.

The noble Lord, Lord Kamall, made a couple of points, which I am happy to write to him about, about concerns about resources. He asked about the role of mental health nurses—an important point—and the effectiveness of CTOs. I will write further on those points.

[Lord Kamall (Con)]

If the Minister and the officials look at Amendment 66, they will see it asks four specific questions. It could include more, but I wonder whether we can understand what the Government understand about each of those four things, including the impact of community treatment orders on people from different ethnic minorities and the effectiveness of the continued use of community treatment orders. I think it would be interesting for noble Lords to understand what the Government currently understand, if that makes sense.

[Baroness Merron (Lab)]

Yes, it does. I thank the noble Lord for the clarification. I will come to some of those points, particularly on racial disparity, but I just wanted to ensure that I did not miss the points that he made.

The noble Baroness, Lady Parminter, raised how people with eating disorders will be supported on CTOs. To elaborate a bit on what I said previously, for some people CTOs allow them to be cared for in the community with the least restriction, but with the safeguard that they can be recalled for treatment if necessary. That is a very necessary aspect.

I hope noble Lords are aware that I certainly would agree about the importance of the right data being used to inform decisions, trends and reviews. Data on community treatment orders are published as part of the annual Mental Health Act statistics. My officials are working with NHS England and others to understand what additional data should be collected to understand the impact of the reforms—this relates to the points made by the noble Lord, Lord Kamall.

I know that noble Lords more than understand that gathering new data takes time. Therefore, it is felt that a review after two years would be somewhat premature, as it would be based on data from before the reforms were commenced. So, rather than committing to a review in legislation at a fixed date, the Government are committed to ongoing monitoring of CTOs as we implement the changes. This will form part of our overall commitment to evaluate the impact of reform and to consider next steps. I am sure that your Lordships’ House would wish to continue to be involved in this.

I turn to Amendment 67, tabled by the noble Baroness, Lady Bennett, requiring a review of economic and social disparities in relation to CTOs. I agree, as I have many times, that there are significant disparities in the use of community treatment orders, particularly between different minority ethnic groups. This was spoken to by not just the noble Baroness, Lady Bennett, but the noble Baroness, Lady Berridge, and the noble Lord, Lord Scriven. I will make a few points about this. Those who are black are currently seven times more likely to be detained on a CTO—we have discussed this in your Lordships’ House a number of times, and rightly so, in my view. For CTOs, we are strengthening decision-making in three ways: first, by requiring that an individual must be at risk of serious harm to be made subject to a CTO; secondly, by requiring that the community clinician be involved in all community treatment order decisions; and, thirdly, by increasing the frequency of automatic reviews of patient cases by the tribunal. We will work closely to ensure that the Bill’s provisions are effectively implemented, because a main plank of this legislation is to reduce racial disparities in decision-making under the Act. I am sure we will return to this point many times, and rightly so.

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[Baroness Berridge (Con)]

My Lords, I will speak briefly to support the amendment tabled by the noble Baroness, Lady Tyler. The extension of advocacy services to children and young people is important, because, as she outlined, there is a disproportionate number of children who are voluntary—I think there are just under 1,000 a year—in mental health institutions.

It is also important to recognise that there are other additional rights that children have when they are detained, or when they have agreed and consented to go into hospital. They need to continue their education while they are in there. It is important to advocate for what their entitlement is while they are in hospital—I think we are all used to walking past the hospital school that is within a normal physical illness hospital—thereby enabling them to continue their education and considering what their rights are in that regard. That is obviously so important for them and their recovery, so I support the amendment from the noble Baroness, Lady Tyler.

[Lord Kamall (Con)]

My Lords, I have a few brief comments on this group of amendments. In response to Amendment 43A, tabled by the noble Baroness, Lady Barker, given that anyone subject to a CTO already receives something in writing, it should not be too difficult for the Government to accept her amendment. Assuming that they have a right to access independent mental health advocates, it seems like a very reasonable amendment.

Like the noble Baroness, Lady Tyler, I must admit that, when I read the amendments tabled by the noble Baroness, Lady Murphy, I wondered—given that the amendments from the noble Baroness, Lady Tyler, and the noble Lord, Lord Scriven, seek to extend access to independent mental health advocates—why she would want to exclude informal patients from access to those advocates. However, as she explained, and as my noble friend Lady Berridge commented on day one in Committee, we have to deal with the world as it is, not the ideal world that does not exist. As the Minister has often reminded us, this will not all happen in one big bang; the Government’s plan is for it to take over 10 years, subject to spending reviews and resources.

In fact, the noble Baroness, Lady Murphy, made what appear to be two valid points. The first is that we need to be realistic about resourcing. As the impact assessment suggests that expanding access to independent mental health advocates to informal patients will cost £81 million every year, we have to ask: is that the best use of that money, if it were available, given all the other demands on it?

On the noble Baroness’s second observation, I thought that the research cited was interesting: that extending these independent mental health advocates from one environment or cohort of patients to another does not necessarily mean that it will work.

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[Lord Scriven (LD)]

I am reading the impact assessment, and the annual amount is between £6 million to £7 million, and not £81 million. Perhaps the Minister could clarify that when she responds, as the impact assessment that I am reading is different from the £81 million that the noble Baroness, Lady Murphy, and the noble Lord, Lord Kamall, are referring to.

[Lord Kamall (Con)]

I thank the noble Lord, Lord Scriven, for that, as I would not want to be using inaccurate information. Maybe the Minister can check with her officials, thanks to the wonderful use of technology, to ensure that we have an accurate figure by the time that she gets up to respond to our points. Whichever number is accurate for the cost of extension, it does have an impact on how noble Lords may feel if these amendments come back on Report.

The study that the noble Baroness, Lady Murphy, shared with us contained two statements which I picked up on, and which I hope the noble Baroness will correct if I am wrong. First, patients found the process was a positive experience. But, secondly, the study found no evidence that it had any impact on the outcomes of the care and treatment. That is an important point to make. Once again, what is effective, and what works? Sometimes, feeling better and being more positive is part of a treatment, and we should not dismiss that.

I do not want to sound too negative, as I thought that the North Carolina study was very positive, and the noble Baroness and I corresponded about this over the weekend. It was interesting that it found that black mental health patients benefited from having an independent mental health advocate, especially if the advocate was also black, as patients felt better supported, and more confident that they would be listened to by someone. The crucial point was that it appeared to reduce the rate of repeat detentions. This is one of the crucial issues throughout the Bill. This is one of the reasons why my noble friend Lady May asked for the Wessely review.

[Baroness Berridge (Con)]

I do not wish to interrupt my noble friend’s flow, but this is one of the key things that is evidence-based, and that does reduce detention for those communities, so it is important.

[Lord Kamall (Con)]

I am grateful to my noble friend for that intervention, because this is something that we could learn from here. Given the point that the noble Baroness, Lady Murphy, made at the beginning, would taking that lesson from the black community in North Carolina work with black communities up and down the country here? I hope it is something that the Government could look into, or respond to, as one of the ways, once we have the relevant data, to reduce the rate of detention and CTOs for people from the black community.

I end by asking the Minister that question: is she aware of whether her department has looked at—was it North Carolina or South Carolina?

[Baroness Murphy (CB)]

North Carolina.

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[Lord Kamall (Con)]

I would not want to upset any people from South Carolina. In fact, I did some work in Raleigh and Durham a few years, so I should get this right. Is the department aware of that study, and has there been any analysis of what could be learned from that study which could be relevant to the United Kingdom, especially given one of the main reasons we are here tonight is to reduce the disproportionate detention of people from black communities? I look forward to the Minister’s responses.

[Baroness Merron (Lab)]

My Lords, I thank all noble Lords who have spoken to and tabled amendments for this important discussion, which, I am sure my Whip will tell me, will be the last one of the evening.

Mental Health Bill [HL]

Lord Kamall Excerpts

Committee stage
Monday 20th January 2025 Lords Chamber

We hear stories about autistic people and people with a learning disability being stuck on wards for an average of nearly five years, where they face being overmedicalised and institutionalised, sometimes to the extent that they can barely get out of bed. These detentions lead to severe lifelong trauma, which can be incredibly difficult to overcome. This leads to an obvious risk of readmission after they are discharged into the community. I feel this is little short of—to use the phrase that the noble Baroness, Lady Browning, used—a human rights scandal, and it has to end. I believe that an explicit focus on therapeutic benefit when delivering treatment is one way that the Bill can help to achieve that. We simply must grab hold of this opportunity.

[Lord Kamall (Con)]

My Lords, given that all those who have spoken to this group of amendments have been brief, I shall try to be brief. Once again, I thank the noble Baroness, Lady Murphy, for discussing with me in an exchange of emails over the weekend the intent behind the amendments in her name.

The noble Baroness, Lady Murphy, makes a reasonable point about clauses in the Bill that contain the phrase “likelihood of the harm” or “serious harm may be caused”, because it is assumed that such risks are quantifiable and predictable. I was struck by her observation that psychiatrists, psychiatric nurses and academics have warned about the difficulty of being able to predict episodes of violent behaviour in individuals because the base rate for violence, particularly serious violence, in the population is low. One of the things that we keep saying throughout this debate is that we need to see the evidence and the data, and that that should drive decisions that are being made. Given that, I am grateful to the noble Baroness for sharing the statistics, which I will not repeat but which reinforce the point that she wanted to make.

Considering those statistics, I am sympathetic to two specific points that the noble Baroness made. The first is that making statements about individual risk based on such statistics is complex and possibly unsafe, and, as the noble Baroness said, may be unethical. The second is that it may be helpful to use structured risk-assessment systems in routine clinical practice, if used by appropriately trained staff, to predict possible violence at a group level. However, given that many noble Lords have spoken about patient-centred care and the importance of understanding the individual and their sensory profile, surely we should be looking at patients as individuals, where the clinician better understands the individual patient’s mental state, relevant history and response to treatment given his or her life circumstances.

I will be interested in the Minister’s response to the amendments in the name of the noble Baroness, Lady Murphy, urging the Government to replace wording such as “likelihood of the harm” or “serious harm may be caused”. These terms are inexact and somewhat ambiguous and do not appear to be driven by evidence. Perhaps there are more appropriate terms for more holistic and comprehensive assessments.

Amendment 45, tabled by the noble Baroness, Lady Tyler, proposes that the definition of appropriate medical treatment includes the setting in which treatment takes place. This takes us back to a point made on the first day in Committee by the noble Baroness, Lady Barker, and just now by the noble Baroness, Lady Tyler, that for those with autism and learning disabilities, being held possibly in noisy, bright, busy settings full of people who may be strange to them, and where they may feel powerless and worry about what will happen next, is likely to affect their mental health and well-being. Therefore, surely it is important that we take account of the points made by the noble Baronesses, Lady Barker and Lady Tyler, particularly in Amendment 45.

On Amendment 48, it is really important that care is led by the level of therapeutic benefit. That should be based on evidence to drive those decisions. Given that, I look forward to the Minister’s response.

[Baroness Merron (Lab)]

My Lords, I am most grateful for the contributions that have been made and the amendments that have been tabled.

I turn first to Amendments 37A, 37C, 38A, 38B, 42B, 42D, 42E, 42G and 42H, all tabled by the noble Baroness, Lady Murphy, and spoken to by other noble Lords, including the noble Lord, Lord Kamall, regarding the new criteria. Let me say at the outset that the new criteria explicitly require decision-makers to consider the risk of serious harm and the likelihood of those harms occurring in order to justify detention. Clearly, the reason for this is to ensure that any risks to the public and the patient are consistently considered as part of the assessment process, and to protect patients from lengthy detention when these risks are unlikely to occur. I hope that this will be helpful for some of the debate that we have had.

The amendments tabled by the noble Baroness, Lady Murphy, seek to revise the proposed new risk criteria to remove any mention of risk that “may be caused” or the “likelihood” of the risk transpiring. The purpose appears to be to remove any prospective assessment from the detention decision and instead focus on the risk as it can be established at the time. The noble Baroness, in her introduction, asked about the reasonableness of the words in the provisions, and I understand that this is where the concerns lie. I should also thank the noble Lord, Lord Kamall, for his comments on evidence and data and their importance. In answer to the noble Baroness, I should say that the independent review found that the current criteria for detention are too vague and recommended that the Government should update the detention criteria to be more explicit about how serious the harm has to be and how likely it is to occur to justify detention. The intention of the revised detention criteria in the Bill is not to ask clinicians to make predictions but to clarify that they should consider whether a harm is likely to occur, based on their assessment and knowledge of the person—something that the noble Lord, Lord Kamall, focused on—rather than based on risks which may never occur.

Any consideration of risk arguably preserves the need to look at what might happen rather than what is happening or has happened in more concrete factual terms. We think that it is important that the detention criteria allow clinicians to detain based on the risks that they think are likely to happen, rather than just the risks that have already materialised. This enables them to act early to prevent harm to the patient or others. In line with the intention of the noble Baroness’s amendments, this should be based on personalised individual risk assessments and information about the patient’s history and personal circumstances—again, something that I know noble Lords are exercised by, which is about the individual approach to this.

We did engage again on the changes to the detention criteria last summer, in light of the recommendation on this issue by the pre-legislative scrutiny committee, and to assure ourselves that the detention criteria struck the right balance between allowing clinicians to continue to take early action when they are concerned about a patient’s or others’ safety and the independent review’s concerns that people could be detained on the basis of risks that might never occur.

Prisons: Health Services

Lord Kamall Excerpts

Tuesday 14th January 2025 Lords Chamber

[Lord Kamall (Con)]

I start by thanking the noble Baroness, Lady Morgan, for sending me a briefing in advance of this Question. She rightly and importantly highlights that cancer outcomes for prisoners are poorer than for the rest of the population, while the cost of services is greater. However, given that we will be debating the Mental Health Bill later today, I want to ask a related question. Over 30% of prisoners have a learning disability, so what steps are the Government, the NHS and the Prison Service taking to protect and care for prisoners with learning disabilities? They may be there partly as a result of their learning disability, and while in prison are often at their most vulnerable. What care is there for prisoners with learning difficulties in order to protect the public and reduce the risk of reoffending when they are released?

[Baroness Merron (Lab)]

As the noble Lord rightly says, the Mental Health Bill is in Committee this afternoon and I know we will refer to that. Certainly, the reforms in the Bill will speed up access to specialist in-patient care and treatment, in particular by introducing a statutory 28-day time limit for the transfer of patients from prison and other places of detention to hospital. On particular needs, which may be learning disability and autism, as I know noble Lords are aware, the Mental Health Bill is very focused on ensuring that people are being cared for in the right places in the right way, and that in places of detention people are being not just held but supported and their healthcare needs met.

Mental Health Bill [HL]

Lord Kamall Excerpts

Tuesday 14th January 2025 Lords Chamber

[Baroness Berridge (Con)]

In supporting Amendment 1, I am delighted that the noble Baroness, Lady Tyler, began Committee with this focus on the impact of the Mental Health Act on racialised communities, because that is where this whole journey began, with the noble Baroness, Lady May, when she was Prime Minister, announcing it in that context—and then, of course, it became a wider reform of the whole Act.

I served on your Lordships’ Joint Committee with the other place, scrutinising the Bill. In the course of that, I became aware of the relative strengths of civil society among some of the groups. There were excellent civil society groups speaking on behalf of people with learning disabilities and autism; they were highly professional and articulate. We had one evidence session on the effect of the Mental Health Act on racialised communities, but I saw that the strength of civil society and of media coverage in that area was less—so I am sympathetic to Amendment 1, which would give a profile to one of the main issues under the legislation.

On whether the table should be in the Bill to be in the code or in the Bill sitting as primary legislation, I have sympathy for that proposition. We have learned that the code of practice merely reflects primary legislation. I am aware, of course, that the independent review came up with those four principles, and this fifth one was not part of that. I expect to hear the Minister say that it is already in the Equality Act, so we do not need to put it in the Bill—but I am persuaded of the merits of the amendment. During the whole process of an independent review, a White Paper, a response to a White Paper, a draft Bill, a Joint Committee and now the Bill before your Lordships’ Committee, it has become clear to me that many of the changes that ethnic minority communities need to see are in practice. They are in resources and training—people would not look to the Bill and see their needs as the first or an important priority in it. I would be grateful if the Minister would take seriously this consideration of putting this equity principle in the table and putting it in the Bill, full stop, and not within the code.

[Lord Kamall (Con)]

I begin by thanking all noble Lords who spoke to this first group of amendments in Committee. Before I comment, I refer noble Lords to my interests as set out in the register. I am not an honorary fellow of the Royal College of Psychiatrists, noble Lords will be relieved to know, but I should mention my previous work with a couple of think tanks—the Institute of Economic Affairs and Politeia, which have both published on health and social care issues. There is also my work at St Mary’s University, where I am a professor of politics and international relations, and which has recently applied to open a new medical school. I also sit unpaid on the advisory board of a start-up coalition, and I know that there are a number of start-up companies helping people with mental health conditions. I just wanted to cover those interests, in case anyone made any accusations.

This group addresses the principles that will guide the application of the Mental Health Act, as set out in the Wessely review. Sir Simon pointed out, rightly, that there are already guiding principles in the code of practice, but that

“there is limited awareness of these, and it seems very likely that they do not inform practice in the way they should”.

Clearly, as noble Lords said at Second Reading, the important aim of including the four principles is to improve their application and ensure the highest level of care and therapeutic benefit for patients, while ensuring that all patients are treated as individuals.

I thank the noble Baroness, Lady Tyler, for her Amendment 1. Of course, equity is at the heart of the Bill, as my noble friend Lady Berridge just said. The Wessely review was commissioned by my noble friend Lady May of Maidenhead with the intention of understanding why a disproportionate number of black people were being detained and receiving community treatment orders under the Mental Health Act. I think all noble Lords welcome the idea of including equity in principle, as long as it then feeds through into practice. That is the key here, and my question for the Minister is: would putting the principle in the Bill make a difference to practice? How do we make sure that it makes a difference to practice, rather than simply adding the words or adding the principle? One of the values in the NHS constitution is that “everyone counts”. Does this equality duty go further than that, and would it have a greater practical significance? That is one of the questions we need to dig out and probe the Government on.

The noble Baroness, Lady Tyler, makes an interesting observation with her Amendment 3. The principles were included in the Bill, as the Wessely review argued, to improve clinical practice. This is vital, because we know that the Mental Health Act is the legislation that is used to compel detention in hospital for treatment. This may very well raise awareness of the principles, but once again, how do we make sure that this is applied? We have to keep pushing this point, although I will not repeat it again, of making sure that this gets fed in to practice in the clinical setting.

I also note the amendments in this group of the noble Baroness, Lady Whitaker. I will not repeat the statistics that she read out about the impact of the lack of or inappropriate support for people with mental health issues or learning difficulties. Of course, it is not difficult to appreciate the complexities. Someone in my close family worked with speech and language therapists in his youth, and I could see the difference it made. It is almost too obvious to say, but how do you get your needs across if you cannot communicate them, or your needs are not understood by the person who is supposed to be offering treatment? As the noble Lord, Lord Patel, mentioned, this is included in the Explanatory Notes, but how do we make sure that it gets into the Bill and into practice? Obviously, it is a problem that is acknowledged by the Government, or it would not be in the Explanatory Notes, but why have the Government chosen not to go any further on this issue?

I was very struck by what the noble Baroness, Lady Murphy, said about Amendment 49 and her concerns. Will the Minister address that debate? Of course, we all want to make sure that patients feel that they are understood. We know that patients have to be supported as much as possible to make sure they get their point across and that they are understood, in order to give them adequate treatment, but I noted the concerns of the noble Baroness, Lady Murphy, even though the noble Lord, Lord Patel, intervened. Have the Government taken a view on this or does the Minister need to write to us? I look forward to her comments.

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

My Lords, I feel it necessary to start, instead of talking about the Bill, by offering our condolences to the noble Baroness, Lady Hollins, on the very recent loss of her dear husband, and to thank her, as I know all noble Lords will do, for her close engagement on these reforms over many years. I say to the noble Baroness, who said she would be watching if she could, that we absolutely understand why she cannot be with us today. We miss her and I know that the thoughts of all noble Lords will be with her at this very sad time.

If I may make a few general points, as we know, this legislation has been in development for many years. I put on record my thanks for the collaborative and constructive nature of that work and the discussions I have held in my post over the past few months with Peers on all sides of the House. I extend my appreciation to the former Prime Minister, the noble Baroness, Lady May of Maidenhead, for her highly significant role in commissioning the independent review which informed this Bill and to Sir Simon Wessely and all those who worked on this landmark review, which provided a blueprint for this Bill. Like other noble Lords, I am very pleased to have got to this point.

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[Baroness Merron (Lab)]

I thank noble Lords for their interventions. I will take the point from the noble Baroness, Lady Berridge, first. Following Royal Assent, we will be drafting and consulting on a revised code of practice, which will be laid before Parliament. We will be working with key partners to ensure that everyone is trained in the new Act before the first major phase of reforms. I hope that that will be helpful.

I hear the disappointment in the comments of the noble Baroness, Lady Barker. On her request for specific examples, I will need to write to noble Lords on that. I hope noble Lords realise that not having the principles in the Bill, as the amendment refers to, does not mean that there is less intention that they apply. For me, it is about the way of getting there, rather than the commitment to it. However, I hear the question about that point.

Amendment 49, on the matter of speech and language therapists, is in the name of my noble friend Lady Whitaker, supported by the noble Lord, Lord Patel, and my noble friend Lord Bradley. I turn first to the question raised by my noble friend Lady Whitaker. It is true that not all speech and language difficulties or differences would count as a disability under the Equality Act 2010, so my noble friend makes a relevant point.

The definition of who can and cannot be approved as an approved clinician was spoken to by the noble Baroness, Lady Murphy, and the noble and learned Baroness, Lady Butler-Sloss. That definition is set out not in primary legislation but in instructions issued by the Secretary of State, under the power in Section 12ZA of the current Mental Health Act. These instructions have the same status as secondary legislation, so it is our belief that it would not be appropriate to specify in primary legislation that speech and language therapists can be approved clinicians, because all other professional groups are covered only in the instructions.

For that reason alone—but noble Lords should bear with me—we will seek to reject this amendment. However, I can commit that we will be revising the statutory instructions under Section 12ZA following the passage of the Bill, and we are very happy to consider extending the criteria to include speech and language therapists. I offer an invitation to the royal college to discuss this matter with the department and to consider how it can work to support and encourage those of its members who may be interested in this role.

I am aware that time is not on my side. However, a number of amendments in this area have been tabled—

[Lord Kamall (Con)]

I wonder whether I can be of help to the Minister. The timing is advisory so, if there are important points that the Minister wishes to make, she should please go ahead.

[Baroness Merron (Lab)]

I have never had so much encouragement to carry on speaking. Noble Lords will be glad to know that the flashing clock always makes me very nervous. I thank the noble Lord, Lord Kamall.

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[Baroness Berridge (Con)]

Perhaps I can clarify. I think that the noble Baroness’s amendment is to some extent based on the spirit of the Joint Committee’s report, which was about providing some kind of mechanism, after the 28 days—I am glad to see the noble Lord, Lord Bradley, nodding. There would be a specialist tribunal, and we said that it should be composed of people with experience of learning disabilities and autism, so that there was not a get-out for clinicians that they had not done the assessments properly. There would have to be grounded reasons to go beyond the 28 days and, in exceptional circumstances, you could authorise the detention, to make sure that the law covered that gap or group of people. No one wanted to see people detained for the reason that there was no community provision—that is ridiculous.

I accept that the reality is probably going to be that clinicians will find a mental disorder diagnosis to use the powers under Part II to do what is in the best interests of that person and their family at the time. But the law should also cover that situation and not force clinicians into those diagnoses—hence the need for accurate data, so that we can track what is happening when the law is enacted.

[Lord Kamall (Con)]

Once again, I am grateful to all noble Lords who spoke to this group of amendments. The purpose of today’s Committee is to probe the Government, but it is interesting that we find noble Lords probing each other—though I have learned a huge amount from these discussions. They say that discourse leads not only to liberty but to an increase in knowledge.

I add my words to those of the Minister and offer my condolences to the noble Baroness, Lady Hollins, who is not in her place today. I recall a debate in 2021 led by the noble Baroness—one of my first as Health Minister—in which she highlighted that people with learning difficulties and autism were being detained in secure settings, even when an assessment had recommended that they should live in the community. This goes back to the words of my noble friend Lady Berridge, who talked about how we can deal with the world as it is and not with the ideal world that we want to live in.

I was shocked at the time by what the noble Baroness, Lady Hollins, told the House about some of the findings from the oversight panel for the independent care (education) and treatment reviews. I bear in mind what the noble Baroness, Lady Bennett, said, when she gave some examples of other countries with much shorter detentions, but I will never forget the story that the noble Baroness, Lady Hollins, told about a Mr W, who had been detained in hospital for more than 20 years, spending most of his time in what amounted to solitary confinement. At the time of the debate, Mr W had been living in his own home for nearly three years, near his family, with his home environment and care being built around his needs. That is something that all noble Lords are trying to push for in this group of amendments. It was not only a heart-warming story but the point was made that, financially, it cost no more to support Mr W living in his own home than it did to detain him in hospital. More importantly, the noble Baroness shared the happy ending that, despite the trauma of being in the wrong environment for so many years, Mr W was, we hope, going to live happily ever after. That highlights the reasons for the amendments in this group.

I should add that I recall the noble Baroness who is now the Minister pushing the Government from these Benches on ending detention. I am sorry—I am going to be a little naughty here, but she can do it if we ever get back into government. She told the House that the average length of stay for people with a learning disability and/or autism in in-patient units was 5.4 years, saying:

“That is 5.4 years that no person will ever get back”.—[Official Report, 28/10/2021; col. GC 231.]


She asked how that could be justifiable when the cost of living in the community was the same as the cost of detention. I know that she is naturally sympathetic to ending these detentions. The detention of those with autism and learning disabilities was one of the central issues addressed by the Wessely review.

I was interested in Amendment 4, in the name of the noble Baroness, Lady Bennett, arguing the definition of “mental disorder” under the Bill. While I am sympathetic to the amendment, can the Minister confirm whether my understanding is correct that the World Health Organization defines a mental disorder as

“a clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour”,

and whether the WHO includes neurodevelopmental disorders, which includes autism? If so, are the Government sympathetic to Amendment 4 and considering bringing forward their own amendment? How would they avoid running contrary to the definition accepted by the WHO and included in the Diagnostic and Statistical Manual of Mental Disorders, particularly DSM-5? I understand the point that these things can change, as the noble Lords, Lord Stevens and Lord Scriven, have very importantly alluded to.

Amendment 5, in the name of my noble friend Lady Browning, seeks to ensure that, if a person has autism or a learning difficulty but not a mental health condition, we should not be using deprivation of liberty safeguards to replace detention under the Mental Health Act. We fully support my noble friend’s amendment and the intention behind it.

I am grateful to noble Lady, Baroness Murphy, who has tabled Amendment 35, for the time she has taken to share her experience and expertise with me and my noble friend Lord Howe. She addresses an issue that we should all be aware of with any legislation: that of unintended consequences. While most noble Lords here today would accept and support ending these detentions, for all the reasons that we have all given, and particularly after the harrowing stories that the noble Baroness, Lady Hollins, told all those years ago, how will the Government ensure that anyone with learning difficulties who could potentially pose a considerable risk in the community receive the required supervision? That is the challenge here, and it is the challenge to which my noble friend Lady Berridge referred when she reminded us that we have to talk about the world in which we live and not the ideal world that we all want.

I am very grateful to my noble friend Lady Berridge for sharing some of the deliberations of the pre-legislative Joint Committee, particularly on the issue of the High Court DoLS. Given that, and the point of the noble Lord, Lord Scriven, if we are to have alternatives, how do we prevent detention by the back door or opening a massive loophole for detention?

Amendment 39, from my noble friend Lady Browning, would ensure that detention was for needs associated with the degree of psychiatric disorder, along with Amendment 40. We are sympathetic to that, and I look forward to the Minister’s response.

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[Baroness Bennett of Manor Castle (GP)]

I thank the Minister for her rich and full response, and indeed all noble Lords who have taken part in this important debate. It has been long but that has been quite necessary. I thank the Minister particularly for responding directly to my question about the UN Convention on the Rights of Persons with Disabilities. I do not agree with her response but I appreciate that she engaged fully with it, so I thank her for that.

I will not go through and summarise all the contributions, but I just want to make two points, which are perhaps specifically directed to the noble Lord, Lord Kamall, and the noble Baroness, Lady Murphy. A phrase which has been missing from our whole debate is the “social model of disability”. That is the idea that society is discriminatory, and that people are disabled by the barriers in society, not by their difference. That position was endorsed by the Government Equalities Office in 2014, and so far as I know, that still holds, and it is preferred by most disability charities.

I invite noble Lords to consider another phrase in this healthcare space, which is “parity of esteem”. I think that when we come to the social model of disability and physical disabilities, most people have now accepted that if there are only steps and not a ramp, that is a failure of society, not the failure of the person in the wheelchair. However, we have not heard in this debate an acknowledgement of the same parity of esteem—the same approach to mental disability as we have accepted towards physical disability—and we should consider and think about that.

In that context, just to pick up a couple of points from the Minister, she talked about how people with autism or learning difficulties can be detained for aggressive or irresponsible conduct. The Trieste model—if I can call it that—which is being adopted by many countries around the world, asks: “Can we intervene before that point and ask what has provoked that person? Can we intervene before we need to detain someone?” That needs to be very carefully considered.

The other point that the Minister addressed, which I confronted myself with, asking why I did not table the broader amendment that I might have done, is what happens when people get to the point of being a danger to themselves or—I stress that this is extraordinarily rare—a danger to others as a result of a mental disorder. Again, how did people get to that point, and should there not be services and support and community wraparound in the Trieste style? I do not think that any nation or area is saying that it has totally got to that point, but surely we should be aiming at that.

[Lord Kamall (Con)]

The noble Baroness referred to the Trieste model, and I thought that led to quite a deal of interest from noble Lords across the House. Could she share some details on the Trieste model with other noble Lords but especially the Minister and the department, so we can all start learning those lessons?

[Baroness Bennett of Manor Castle (GP)]

I should absolutely stress at this point that I am not an expert, but I will certainly do my best to secure as much information as possible and share it with all noble Lords. The Minister may also have access to resources that may not be available to me. Reflecting on the intervention of the noble Lord, Lord Kamall, perhaps we could even arrange some kind of discussion—it might be useful—and perhaps even hear some testimony, because that would really inform our consideration of the Bill. But in the meantime, I beg leave to withdraw the amendment.

Mental Health Bill [HL]

Lord Kamall Excerpts

Tuesday 14th January 2025 Lords Chamber

[Lord Kamall (Con)]

My Lords, I am sure the noble Lord is thinking, “If only all groups went as swiftly as this one”. I thank him for bringing forward these government amendments. We understand that although they are largely technical in nature, they address some important points regarding the delivery of aftercare services, tribunal reviews and the broader application of this legislation.

We see the point of Amendments 7, 14, and 127 to clarify the references to aftercare services under Section 117 of the Mental Health Act, including services arranged by public authorities in addition to those directly provided. We understand that this reflects the practical realities of service delivery and may help to avoid ambiguity in how these obligations are interpreted. If we have heard any lesson throughout this debate, it is about how we avoid ambiguity when it comes to the treatment of patients.

We understand also that Amendments 87 to 94 focus on tribunal reviews for patients subject to conditions amounting to a deprivation of liberty, which we have discussed in other groups. The proposal to commence these provisions two months after Royal Assent is pragmatic and necessary to provide patients with timely access to justice. The amendments also introduce a new clause requiring the Secretary of State to refer certain cases to the tribunal within defined timelines. We agree that this will ensure that patients who are conditionally discharged but not recalled to the hospital are not left in a state of indefinite uncertainty. Once again, that was covered in the last group of amendments as somewhere where the patient could fall between the cracks, as it were. Timely tribunal reviews are essential for safeguarding patients’ rights and ensuring that any conditions imposed remain proportionate and necessary.

We understand also that Amendments 161 and 162 propose adjustments to the commencement of specific provisions, including granting Welsh Ministers powers to make consequential provisions within their devolved competence. Though these amendments are largely procedural, they underline the importance of clarity in implementing the reforms set out in the Bill. Of course, we understand that healthcare is a devolved matter. I remember having to deal with the devolved Administrations when I was a Health Minister, and we always did so collaboratively. Welsh Ministers should indeed have the same right to make consequential provisions, although if I have a question for the Minister, it is: what safeguards and oversight mechanisms will be in place to ensure equal application of the Bill to Wales, as in England? I am sure he will be aware that we have sometimes had questions in this place as to why the standard of health or social care in another part of the United Kingdom might be different, even understanding that it is due to devolution. Are there any safeguards to ensure that one part of the UK is not seen as having an inferior service to the rest of the UK? How would the Government address that?

With that, we very clearly understand that these are technical amendments and we will not oppose them.

[Lord Cryer (Lab)]

I am grateful to the noble Lord and take his point about ensuring there are equal standards across the devolved Parliaments and Assemblies. However, nothing is guaranteed. As he undoubtedly did when in government, we will endeavour to collaborate with Welsh colleagues—as well as others—to ensure that equal standards are applied across England and Wales. That includes regular contact with the Senedd and the Welsh Executive on a variety of matters, including health. That may be a slightly vague answer, but at the moment it is the best I can do.

I thank the noble Lord for his other comments. I have spoken about the need for these minor, technical and necessary amendments, and I hope noble Lords can support them.

[Lord Kamall (Con)]

This raises another issue, which I know has been raised in other areas of healthcare, of families who live across borders—if the parents live in one part of the United Kingdom and the children live in another, or if someone who has lived away from home moves back. I do not expect an answer now, as that would be unfair, but if the noble Lord could write to noble Lords on cross-border issues, where someone has commenced care in one area but then they or their parents have moved to another area, that would be satisfactory. We had a number of issues around this in healthcare, particularly mental health care, and it is important to resolve them.

[Lord Cryer (Lab)]

I am happy to do that. I remember having those sorts of issues when I was a Member of the other place. Probably a number of us have experienced them. I suppose that, at present, it is how it has always been: you have to try to communicate with the respective authorities and bring them together so that there is some sort of continuity.

Adult Social Care: Long-term Workforce Plan

Lord Kamall Excerpts

Monday 13th January 2025 Lords Chamber

[Baroness Merron (Lab)]

Retention is absolutely crucial. I was looking—as I know the noble Lord also does—at the vacancy rates and they are currently running at some 131,000. However, I was interested to note that they are not actually the best measure of capacity, or lack of it, because those vacancies can reflect new roles and short-term vacancies because of anticipated staff turnover. So I have had to rein myself in when looking at the relevance of vacancy rates.

On retention, there is a whole range of factors. In the immediate, I say to the noble Lord that we are professionalising the workforce by expanding the national career structure and have developed and launched a level 2 adult social care certificate qualification.

[Lord Kamall (Con)]

My Lords, as the Government and the NHS introduce new workforce patterns to take account of changes, surely they should also take account of advances in technology. Recent years have seen the successful testing of virtual wards in the NHS to treat and monitor patients who can be discharged from hospital but who require further care. They can be monitored in their home, freeing up capacity in hospitals. Given this, what are the Government and NHS doing to extend virtual social care to monitor care for social care patients? It would allow them to remain in their home for longer, where they are more comfortable, and it could be one of the many ways to alleviate workforce shortages in the social care sector.

[Baroness Merron (Lab)]

I myself have seen some tremendous examples of the use of technology in allowing people to be in the right environment for themselves and their situation. I assure the noble Lord that we are continuing to work to develop medical technology, not just getting it rolled out and applicable but developing new medtech where necessary.

Perhaps I could use this opportunity to make an allied point. We have also published new guidance on safe delegation to care staff, which I hope will also help professionalise the workforce. We are working to support that across the country. That includes, for example, having care staff taking blood pressure. These are simple but obvious measures that I think work for everybody.

NHS: Single-sex Provision for Staff and Patients

Lord Kamall Excerpts

Wednesday 8th January 2025 Lords Chamber

[Baroness Merron (Lab)]

I am sorry to hear of the noble Baroness’s experience, which I have heard her speak of before. To me, as I said earlier, it points to the need to treat people with respect, with dignity and without making assumptions. I cannot emphasise enough the need for sensitivity and respect, which applies to everybody.

While we are talking about changing facilities, we should think about the huge difference in shops over the years. There used to be communal changing rooms, but you would be hard pushed to find them now. People have private spaces for changing and this again applies to everybody. I recognise the challenge of the NHS estate, of course, but I am talking about creative solutions and working with staff to get to where we need to be.

[Lord Kamall (Con)]

My Lords, the noble Baroness is absolutely right to talk about dealing with this issue very sensitively, by respecting people’s dignity and acting with compassion. However, some NHS staff and patients—the noble Baroness, Lady Fox, referred to this—have asked for single-sex provisions to protect their privacy and dignity. If the Government are planning further guidance, how do they intend to achieve that difficult trade-off and balance in potential conflicts between single-sex provisions for NHS staff and patients and the rights of individuals under the Equality Act 2010, while respecting their dignity and acting with compassion?

[Baroness Merron (Lab)]

The noble Lord raises an interesting point. In all cases with guidance, that is always the balance we seek to reach. I am also interested in the history of this, and I am sure the noble Lord will remember that the 2019 guidance on trans patients in single-sex spaces proved somewhat controversial, if I might put it that way. The guidance was meant to be updated under the last Government, but this did not happen. I am advised that it was delayed by a dispute between the previous Government and NHS England, which also delayed proposed updates to the NHS constitution. These again were consulted on under the last Government—which was a good thing—but nothing actually happened. So all these come to us as a new Government and will be given full consideration to get us into the right place.

Health: Obesity

Lord Kamall Excerpts

Tuesday 7th January 2025 Lords Chamber

[Baroness Merron (Lab)]

The noble Lord raises a very interesting point. It is certainly the case that those who consume ultra-processed food have around 50% of their calorific intake through that matter. Where there is not clarity is on whether the foods are unhealthy due to processing or to their nutritional content. On that, the jury is out. We need to establish that. That is the why the Government’s Scientific Advisory Committee on Nutrition has concluded that the association between UPFs and health is concerning. We need to get to the bottom of why that is.

[Lord Kamall (Con)]

My Lords, the Minister rightly talked about the importance of creating the right environment for people to eat healthily. Some noble Lords may have seen daytime television programmes that help families to eat healthily on a budget. The challenge has always been how we take these lessons into people’s homes. I recently spoke to BRITE Box, a local community charity which gives families the ingredients and a recipe card with instructions to help them to cook healthy meals together. This helps with not only budgeting but addressing obesity. Rather than a top-down approach from the Government, what steps are they and the NHS taking to work with existing projects such as BRITE Box to take a bottom-up, community-led approach to tackling obesity?

Health and Adult Social Care Reform

Lord Kamall Excerpts

Tuesday 7th January 2025 Lords Chamber

[Lord Kamall (Con)]

My Lords, I begin by echoing the comments made by my right honourable friend the shadow Secretary of State in the other place in support of all those who worked in the NHS and social care sectors over the Christmas period. They sacrificed their time, which could have been spent with their friends and families, to care for those most in need.

On the NHS app, we support the digitisation of health and care to modernise the NHS, and support digital patient records to allow joined-up health and social care to deliver better outcomes for patients and to inform patients. However, the NHS app already sends appointments and updates on treatment to some patients, while some GP surgeries prefer patients to use their own website, not the app. I would be grateful if the Minister could expand on how the updated app will differ and offer up further information to your Lordships’ House. Also, where your GP cannot see you, is the plan to allow all patients to book an appointment with another GP without having to deregister from their current practice and reregister with another practice? Will that be allowed with the updated app? One of the problems was always where there were GPs who could not see their patients but other GPs in the same area had spaces on their lists.

In the Statement, the Secretary of State said:

“We are rewarding trusts that cut waiting times fastest”,


and the carrot of “extra capital investment” is used as an incentive. This appears to make sense, but noble Lords will know that I have always been interested in potential unintended consequences. If the Government reward trusts with extra investment if they cut waiting times fastest, what will happen to those trusts that are not able to cut their lists as quickly? Will they see reduced investment, and will that simply lead to them continuing to perform poorly? What is the solution? Will hit squads—in the best possible terms—be sent in to turn them around? What other plans are there to tackle underperforming trusts which do not qualify for these extra incentives? How do the Government and NHS intend to avoid perverse incentives such as trusts prioritising certain patients over others—not necessarily based on medical needs—to cut waiting times to win this extra cash? How do we avoid that?

On social care, I appreciate the candour of the Statement in acknowledging that Governments of all colours, for decades, have not really dealt with this problem of long-term social care. As my right honourable friend the shadow Secretary of State said in the other place, we will work with the Government and the commission. However, I will put a few observations to the Minister. For decades, successive Governments have known about the ageing population, and Governments of all colours have commissioned report after report, which mostly gathered dust on the shelf. Although I have the greatest respect for the noble Baroness, Lady Casey, given that most commentators on social care agree that everything to be written about funding social care has already been written, I am curious to know what the Government expect to achieve by initiating yet another commission.

A solution was proposed in the Health and Care Act 2022. Noble Lords welcomed that we finally had a solution but disagreed on some of the details. But we had a solution to which the Treasury agreed. I remember the Opposition criticising the Government not for introducing the social care cap but for not doing it earlier, and they also suggested a number of tweaks. The incoming Government could have tweaked the numbers to address the concerns that they expressed at the time, and they could have grasped the nettle, but I am afraid that the announcement looks like yet another Government kicking the can down the road. So will the Minister write to noble Lords with the terms for the commission led by the noble Baroness, Lady Casey? This time, will the Department of Health and Social Care continue to work with the Treasury to ensure that whatever solution is finally proposed, even if it is likely not to be a new solution, has the agreement of the Department of Health and Social Care, other government departments and the Treasury? If not, it will simply find itself kicking the can down the road yet again when it comes to 2028.

My final point is on how to cut the backlog. These Benches welcome the Government continuing the policy of the last Government in opening new surgical hubs and community diagnostic centres at weekends and evenings. But, when we were in government, we found a potential workforce issue in opening community diagnostic centres at weekends and evenings. Of course, there are only so many staff who can be employed to keep these services open for longer, so have the Government made an assessment of how many staff they envisage will be available to keep these centres open for longer hours? What is the plan? Will it be a redeployment of existing staff, will existing staff be asked to work longer hours and overtime, or will they recruit new staff?

[Lord Scriven (LD)]

My Lords, we on these Benches welcome the Statement and can see some positives in the way forward, but we have some reservations about timescales and unintended consequences in the implementation that I would like to explore with the Minister.

On social care, we have already called for cross-party talks, as many noble Lords will know. Social care is in crisis and at a tipping point, and it is an unbearable pressure for many families. But we cannot understand why the review will take until 2028 and full implementation will probably not happen until 2029-30. It is a bit like calling the fire service when your house is on fire and asking it to attend once it is out. So what specific components of this review that are not already in the public domain have the Government already determined will take until 2028 to be dealt with? Will the review tackle all forms of social care, including continuing care and young people’s services?

The NHS elective reform plan marks a significant initiative for reducing waiting times and enhancing patient access to elective care. The plan introduces some welcome measures, but many are not new, such as the expansion of the diagnostic and surgical hubs, increased utilisation of digital platforms such as the NHS app and a commitment to meeting the 18-week referral to treatment standard by the end of this Parliament. Although these proposals are commendable, I have been of the view for many years that elective and emergency care need to be provided in different, and probably separate, ways. Several critical concerns warrant attention to ensure the plan’s success and sustainability.

A primary concern is that the plan focuses predominantly on elective care, potentially overlooking the broader health and social care ecosystem. The Nuffield Trust emphasises that, for the plan to be sustainable, there need to be concurrent reforms in social care, significant investment in community services and attention paid to the determinants of ill health, such as housing and education. The focus on throughput measures will mean that it will be focused purely on those. What outcome measures will be put in place, not just for the quantity and speed of care but for the clinical outcomes for patients?

The emphasis on meeting elective care targets should not overshadow other clinical priorities. It is critical to ensure that resources allocated to elective procedures do not detract from urgent and complex care needs. Indeed, the financial model set out in the plan on tariffs will create incentives to focus on elective cases when budgets are stretched. What measures will be put in place so that the expanded diagnostic and surgical hubs, along with the extra reported 3.5 million procedures in the independent sector, will avoid pulling staff away from urgent care and complicated patient needs? This must be based on a fully costed workforce plan, so when will that be presented?

The plan has been announced with little firm detail on funding, especially considering that the £3 billion ring-fenced for cutting waiting times this financial year will not be available from April. Will this ring-fenced scheme be reintroduced? While we welcome the thrust of this plan, there will be some unintended consequences, and we really need to see a detailed implementation plan to ensure that elective care does not overshadow emergency care and those seeking social care.