National Cancer Plan

Lord Scriven Excerpts

Monday 10th February 2025 Lords Chamber

[Lord Kamall (Con)]

My Lords, I thank all those who work tirelessly to treat and help others who are suffering from cancer—not only the wonderful clinicians and medical professionals but also the many cancer charities, some of which I have met, which support people living with cancer and fund the important research that has led to significant increases in survival rates for some cancers and will lead to the future breakthroughs that we all want to see. Their dedication is an example to us all. We owe them a great deal of gratitude; it is something that we can all be proud of.

Cancer will affect us all in some way or another. Almost everyone knows someone who has been diagnosed with it or may have had to live with the big C themselves, so it is vital that we do everything we can to beat this disease. It is highly reassuring that cancer care and treatment are constantly improving. Over the past 50 years, the survival rates for all cancers have doubled. The one-year survival rates for cancer increased by almost 6% between 2010 and 2020, while the five-year survival rate has increased by more than 4%. However, we know that more can and must be done. Despite these improvements, we are not in the place we all want to be in. We should be honest about that.

These Benches welcome the fact that the Government are taking steps to try to improve cancer care and research. It is welcome that there will be a greater focus on prevention and early diagnosis, which we know to be one of the best ways of improving quality of care. We are also grateful to this Government for continuing the rollout of community diagnostic centres started by the last Government.

When I was a Health Minister, I was advised by officials that 80% of those on the waiting list were waiting for diagnosis. That statistic may no longer be true but more community diagnostic centres are clearly needed, not just for early diagnosis but because their being placed in local communities might help reluctant patients who are scared or worried about going to hospital or who suffer from white coat syndrome to seek a diagnosis—at a more friendly place such as their local sports centre or shopping centre, so it does not become a daunting task. We welcome the fact that the Government will continue to roll these centres out.

Technology will be an accelerator for cancer treatment. Coupled with innovative methods of utilising data, machine learning and AI, there are real opportunities to drive better outcomes. If we can identify those who are more at risk or likely to be at risk from certain types of cancer and streamline them into treatment pathways using the best data available, then we could increase our survival rates further. Can the Minister reassure your Lordships that there will be a strong focus on harnessing new technologies in the cancer plan when it is published and will the Department of Health and Social Care engage with the many innovative companies—start-ups and others, and rollouts and spin-outs from many research places—that produce such technologies and can help the NHS synthesise and restratify the available data?

While we welcome the Government’s commitment to cancer care, we have questions about the timescale. I appreciate that the Minister has been honest that some announcements by the Government are aspirations while others are firm commitments. I note that this announcement launches the call for evidence for the national cancer plan, but we have already heard that the Government have launched a number of other reviews and plans. We have the NHS 10-year plan, the elective reform plan, the commission on building the national care service and the review of the new hospital programme. I believe noble Lords would like to know when we will see action from these plans, and today in particular from the cancer plan. If the Minister cannot give further details now, can she give an indication of when we can expect them? That would be greatly appreciated when it comes to understanding the Government’s commitment to this plan.

Finally, while we have made great progress in tackling certain types of cancer, what more could be done to speed up treatment of the hard-to-treat or less survivable cancers? I recently met Pancreatic Cancer UK, which told me that one of the reasons for lower survivability is that, by the time the cancer is spotted, it has often reached a late stage: stage 3 or 4. It also told me about a breath test being trialled that captures vapours and gases which can be analysed to detect the presence of biomarkers of certain cancers. To be clear, I appreciate that this is being trialled, but I wonder what changes to processes the Government and the NHS may be looking at to speed up the rollout of such innovations, especially relatively low-cost tests. I appreciate that there might be unintended consequences, false negatives or false positives, but could the Minister write to noble Lords with more details of such forthcoming breakthroughs and trials in England? I look forward to her response.

[Lord Scriven (LD)]

My Lords, I thank the Minister for the Statement. Like the noble Lord, Lord Kamall, I thank those individuals who work day in, day out with people who have been diagnosed with cancer, and with their families, for the great work they do. This cancer plan represents an opportunity to make significant progress in the country’s fight against this terrible disease. The Statement and the plan, while containing some promising elements, require careful scrutiny. In the view of these Benches, further action is required if we are truly to make the necessary strides in the fight against this devastating disease.

Cancer, as we all know, touches every family in the country. It is a relentless adversary and our response must be equally determined. The plan before us rightly acknowledges the importance of early diagnosis and I commend the focus on initiatives such as the expansion of screening programmes and the innovative use of technology to detect cancers earlier. Early detection is, without question, the single most powerful tool we have to improve patient outcomes.

However, we have some concerns. While the rhetoric around early diagnosis is welcome, the plan lacks sufficient detail on how we will address the very real workforce shortages that plague the NHS. We cannot diagnose cancers early if we do not have the radiologists, pathologists and oncologists to interpret results and deliver timely treatment. The Government need a concrete plan for recruitment and retention of these vital professionals. I urge them to address these critical gaps and ask the Minister exactly how these gaps will be plugged.

Furthermore, the plan’s ambition for personalised medicine is laudable, but it seems somewhat detached from the realities on the ground. Access to cross-cutting treatments and clinical trials remains uneven across the country. We must ensure that one’s postcode does not determine a patient’s access to the most innovative therapies. This requires not only increased funding for research and development but a streamlined process for bringing new treatments to patients as quickly and safely as possible. What plans do the Government have to ensure that these treatments are brought forward quickly across the country?

Another area of concern is the plan’s approach to palliative care. While the focus on early diagnosis is crucial, we must not forget those for whom a cure is no longer possible. Palliative care is not simply about end-of-life care; it is also about maximising quality of life for patients and their families throughout their cancer journey. What are the Government doing to ensure a renewed focus on funding and resourcing for palliative care services, ensuring that every patient receives the compassion and holistic care they deserve?

We need to do more to tackle what is happening. I will ask two further questions and give the Minister a suggestion that may be taken forward. First, it is pleasing to see that radiotherapy is in the Statement, which is a step forward. However, evidence shows that currently the United Kingdom allocates only 5% of its cancer budget to radiotherapy, compared with the OECD average of 9%. This discrepancy is a contributing factor to the UK’s low cancer survival rates, particularly in cancers such as lung and colorectal. Countries such as Australia and Canada, which allocate a higher percentage of their cancer budgets to radiotherapy, have seen improvements in survival outcomes. Will the Minister commit to addressing this funding gap and set specific targets for cancer budget allocation for radiotherapy to ensure better survival rates for patients in the UK?

Secondly, with over 500,000 people waiting more than two weeks for vital cancer treatment, how do the Government intend to tackle these extensive delays in the immediate term? What concrete measures will be taken to ensure that the national cancer plan leads to real improvements, rather than remaining a set of unmet promises?

I wish to give the Minister a suggestion, which I hope she will take forward. Many of us in this House understand the significant difference in outcomes between early and late-stage diagnosis of cancers. On these Benches, we are strong advocates of utilising AI in early detection. The UK, with its unique history of the National Health Service, benefits from a collection of historical tissue samples. Given this, would the Government implement a programme in which AI performs a retrospective analysis of these samples in order to identify patterns that would improve the speed and accuracy of cancer diagnosis in the future?

I urge the Government to listen to the concerns raised by healthcare professionals and, most importantly, by patients and their families during the consultation period. These insights will strengthen this plan and ensure that it delivers real and lasting improvements to the lives of those affected by cancer.

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

My Lords, I am most grateful to both Front Benches for welcoming the plan and coming forward with very constructive points to strengthen our hand. I am sure we all agree that the prevalence of cancer and the way it touches everybody’s lives, either directly or indirectly, are considerable; cancer affects one in two people in this country. I also thank the staff, volunteers, researchers and everybody who is involved, including carers—paid and unpaid—for their work in this area.

The Statement was made on World Cancer Day. There were two aspects to it; both have been raised, but the one on which I want to focus is the national cancer plan. We have opened a call for evidence to gather views from the public, health partners and parliamentarians on what should go in the national cancer plan, because it seeks to improve every aspect of cancer care and to improve the experience and outcomes for people with cancer, including key goals and actions. The call for evidence is open until 29 April and, to the question raised by the noble Lord, Lord Kamall, it will report in the second half of this year, which, as I hope the noble Lord will agree, in government terms is quite prompt. It will follow the publication of the 10-year plan. In the Front-Bench questions, there was reference to various plans. They all chime in with and build on each other, but we feel that, as noble Lords have said, cancer is absolutely something on which we have to focus.

On radiotherapy access—an important point raised by the noble Lord, Lord Scriven—this is a priority, which is why this year we will spend £70 million in investment to replace older radiotherapy machines with newer and more efficient models. This will mean at least 27 machines to trusts across England, because we are keen that improvement is made.

It has come up in previous debates that NHS England and integrated care boards are responsible for ensuring that the healthcare needs of local communities are met. I take on board the point raised by the noble Lord, Lord Scriven, about concerns over differences of availability of care. In my view it is a good thing to move to give more decision-making and powers locally to meet the needs of local communities, rather than be instructed from the centre. Responsibilities for local provision include considering adequate healthcare provision, such as radiotherapy treatment, care and wider support, including in remote and rural areas. Of course, addressing healthcare inequity is a core focus of the 10-year health plan. We have established working groups focused on how care should be designed and delivered to improve equity and make sure that services are effective and responsive.

Cancer survival is indeed an area in which this country lags behind. That is a consequence of a number of issues, including diagnosis not being where it should be. Improving early diagnosis of cancer is integral for improving survival rates, and it is a priority both for the Government and for the cancer plan. The noble Lord, Lord Kamall, talked about recent successes, including the CDCs, but there is also, for example, the targeted lung cancer screening programme, which has been a tremendous boost to survival rates and to diagnosing cancer earlier in the groups and individuals who are more at risk and yet were not coming forward. We will continue to work from that.

The noble Lords, Lord Kamall and Lord Scriven, both raised rare cancers and research. There will be careful consideration of how the plan is going to deal with rare cancers so that they are not left behind. We absolutely recognise the importance of research and harnessing the powers of new technology to improve outcomes. That is why we invest more than £1.5 billion per year through the National Institute for Health and Care Research, which will help that prevention and detection.

The noble Lord, Lord Scriven, raised the important matter of AI. Your Lordships’ House will be pleased to hear that the other part of the cancer plan was to launch a world-leading artificial intelligence trial, involving nearly 700,000 women and using the latest AI technologies to catch breast cancer earlier. The noble Lord asked a specific question about the use of AI retrospectively, which I would be pleased to look into and get back to him on.

With regard to shortages in the workforce, we have already announced plans for a revised NHS Long Term Workforce Plan for the summer of this year, to make sure that the NHS has the right people in place.

To go back to the point raised by the noble Lord, Lord Scriven, on clinical trials, I should add that the TRANSFORM trial will look for better ways to detect prostate cancer and address the health inequalities that we know are there by ensuring that one in every 10 of the participants are black men.

The noble Lord, Lord Scriven, raised the important matter of palliative care. We will consider palliative care and other care for people living with and beyond cancer as a part of the cancer plan. We would very much welcome responses to our call for evidence on this.

On waiting lists, on 6 January 2025, a new elective reform plan was published to set out a whole-system approach to reaching and meeting the 18-week referral to treatment target by the end of this Parliament.

The noble Lord, Lord Kamall, asked about harnessing data, which is very important. As I mentioned, we have launched a world-leading AI trial, which will provide us with the kind of data we need to improve women’s health screening.

I am grateful to noble Lords for their support and suggestions. I look forward to this cancer plan making significant changes for so many in this country.

Medicines for Human Use (Clinical Trials) (Amendment) Regulations 2024

Lord Scriven Excerpts

Monday 10th February 2025 Grand Committee

[Lord Scriven (LD)]

My Lords, I start by congratulating the Minister; I hear her sniffles. She has been a champion of her brief in having to deal with two statutory instruments, as well as a Statement in the House. I thank her for being here.

As the Minister said, the reforms proposed in this statutory instrument aim to create a more streamlined and flexible regulatory environment for clinical trials in the United Kingdom, while balancing safeguarding the interests of trial participants. The amendments seek to uphold the paramount importance of participant safety, ensuring that their rights and well-being remain central to the regulatory framework. By refining the evaluation and development process for new or improved medicines, these changes aim to expedite the delivery of therapeutic benefits to patients and society at large, and we on these Benches recognise that.

The instrument will formalise the combined review process, which has been piloted since 2018 and become the exclusive route for clinical trial applications. This process offers a single application pathway and co-ordinated regulatory and ethics committee review, ending in a unified UK decision for clinical trials. That would be helpful for practitioners and those seeking to innovate, but there are still points that require clarification, and while the objectives of these amendments are commendable, I seek clarification from the Minister on several aspects.

What measures are in place to ensure that the Medicines and Healthcare products Regulatory Agency and the ethics committees will be adequately resourced to manage the anticipated increase in workload resulting from the streamlined process? If no impact assessment has been made, what working assumptions are the department and NHS England working to regarding the workload that this new process will bring?

Can the Minister provide detailed guidance on how the risk-based approach will be operationalised to ensure consistency across different types of trials? I note that she talked about international alignment, but how do the Government plan to align these regulatory changes with international standards to facilitate seamless multinational trials? What frameworks will be established to monitor the impact of these regulatory changes on trial efficacy and patient safety, which is really important? How will these findings be reported locally within the NHS? Will they be reported to Parliament at any point?

Finally, can the Minister explain and elaborate on the consultation process undertaken with key stakeholders regarding these changes, including patient groups, industry representatives and academic researchers, in the development of these amendments? Were there any differences that emerged from the stakeholders and how have the Government dealt with them?

In conclusion, while we on these Benches support the intention behind these regulations, it is imperative to ensure that the implementation is robust and effective. I look forward to the Minister’s responses on the matters I have raised—less croaky responses, I hope.

[Lord Kamall (Con)]

My Lords, I thank the Minister for the laying of this statutory instrument. Like the noble Lord, Lord Scriven, I commend her on her valour and robustness, as well as the speed at which she managed to transport herself from the Chamber to here after the Statement repeat, having prepared for that and having been briefed by her officials.

Like many other noble Lords, we welcome these regulations, which are grounded in the review by my noble friend Lord O’Shaughnessy and the subsequent consultation with stakeholders, including the Medicines and Healthcare products Regulatory Agency and Health Research Authority, aimed at modernising the regulatory framework that governs clinical trials in the UK. We know that the landscape for clinical research in the UK faced significant disruption during the Covid-19 pandemic, but we also know that we learned quite a lot from trying to get vaccines out very quickly in terms of ways to speed up trials and to make sure that we get the right balance between efficiency and processes, as well as making sure that people are safe. We need to make sure that we can boost the volume of clinical trials and boost patient recruitment.

The O’Shaughnessy review identified the need for a more flexible and risk-proportionate approach to clinical trials. One very important point is that, while we cannot eliminate risk altogether, we can manage it. Where there is low risk, we should maybe not be placing so much emphasis on processes as compared with when there is high risk, but I also know that there may always be unintended consequences.

Stakeholders such as the Association of the British Pharmaceutical Industry were vocal in their support for these reforms and had in fact been calling for them. The ABPI 2024 report, The Road to Recovery for UK Industry Clinical Trials, highlighted that the number of pharmaceutical industry trials initiated in the UK increased—it was just over 400—between 2022 and 2023, although that still remained 36% below the 2017 level. We therefore understand the need to bring forward these regulations to make sure that we improve the regulatory environment to further increase clinical trial activity.

I turn to the detail of the regulations. One major change that noble Lords have already alluded to is the consolidation of the regulatory and ethics review process, enabling researchers to submit a single application for both regulatory approval and ethics review. While this change is aimed at improving efficiency—which we completely accept and welcome—there is a concern that any changes from consolidating these processes may put additional pressure on the regulators and ethics committees. The noble Lord, Lord Scriven, referred to that. If the single application process becomes overloaded, we risk delays in review times rather than the acceleration that was intended by these measures in the first place. It is essential that we have the resources and infrastructure in place to handle the increased workload effectively. Can the Minister therefore say how the Government will make sure to avoid that sort of overload? We completely understand why they want to consolidate the processes, but will it add extra pressure and will the resource be there to make sure that they are not overloaded and we do not just end up going back to square one, or even make things worse?

In addition, for low-risk trials, automatic regulatory authorisation will be granted, which will further streamline the approval process and free up resources for the more complex, higher-risk trials. Once again, while this makes sense, we have to be aware of possible unintended consequences or concerns that will be raised. The automatic approval of low-risk trials could, for example, raise concerns over oversight and monitoring. The intention to expedite the approval process for those with lower-risk profiles is laudable, but will there be clear criteria in place to ensure that the appropriate level of scrutiny is maintained, particularly in ensuring patient safety? As I said, while we support the intention, particularly for low-risk trials, we must always be aware of unintended consequences or unforeseen complications. Nevertheless, we completely understand why this is being done, and it is something to be welcomed.

Health and Social Care Act 2008 (Regulated Activities) (Amendment) Regulations 2025

Lord Scriven Excerpts

Monday 10th February 2025 Grand Committee

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

My Lords, this SI amends the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which are due to expire after 31 March this year. It removes that expiry date and amends the five-year period from which the regulations are required to be reviewed. Prior to laying this SI, the principal regulations required review every five years from 1 April 2015. The first post-implementation review was delayed until 2022 due to the pandemic. We therefore wish to conduct the next review in 2028.

This SI does not change any existing policy. The 2014 regulations set out the activities that are regulated by the CQC and the fundamental standards with which all health and social care providers registered with it need to comply. This is coming before your Lordships’ Committee because, if we do not amend the 2014 regulations, they will automatically expire and the CQC will have no powers to fulfil the requirements in the 2008 Act. Neither will there be an obligation on providers, which are currently required to register with the CQC, to comply with the fundamental standards set out in the 2014 regulations.

I am aware that there may have been an expectation to see further changes following the report by Dr Penny Dash into the CQC’s operational requirements, which uncovered significant failings in the CQC’s internal workings. However, dealing with those operational failings does not require changes to legislation; as we have debated in the Chamber on previous occasions, measures have been put in place by the CQC’s new chief executive, Sir Julian Hartley, to urgently address the failures, including the introduction of new governance at the board level.

Noble Lords may also have observed that this SI is silent on provisions relating to the use of restraint and the regulation of medical care at temporary cultural and sporting events, on which we also consulted last year. I can give an assurance that these sensitive areas have not been overlooked and that we are continuing to progress work on finalising these policies.

The consultation responses on the proposal to make restrictive practices notifiable to the CQC within 72 hours showed support for the measures but highlighted a number of practical concerns, primarily that the proposed timeline could place an additional burden on staff, with the potential risk of impacting patient care. As the Government said in their response to the consultation, further work is needed to ensure that we have the right definitions, systems and processes in place before proceeding with legislative changes.

I can tell the Committee that the Government will lay a statutory instrument to remove the exemption relating to regulation of medical care at temporary and cultural sporting events. With this change, providers of such care will be required to register with the CQC for the first time. I hope that will be helpful in setting out what this SI is, and is not, about. I beg to move.

[Lord Scriven (LD)]

My Lords, again I thank the Minister for clearly and aptly outlining what the statutory instrument is for. I am not going to go over the reasons for this but, broadly, these Benches support what is happening and understand why the streamlining is required. However, like all streamlining where common sense seems to take the central point, it is worth testing just how common and sensical the requirements are, and whether the Government have thought through some of the consequences—or unintended consequences—of what may happen. Although the intention to maintain regulatory oversight and uphold care standards is obviously commendable, several points warrant further investigation and probing. I hope that the Minister will answer in her normal way; she is usually quite thorough and detailed.

The Explanatory Memorandum notes that a post-implementation review conducted in July 2022 had limited responses, providing insufficient evidence to suggest that the 2014 regulations did not meet their original objectives. Could the Minister elaborate on the steps taken to engage stakeholders during this review? What measures will be implemented to ensure that, when statutory instruments are extended in future, more comprehensive stakeholder participation will be sought? The amendment mandates having a review every five years. Given the dynamic nature of health and social care, how will the Government ensure that the regulations are monitored and remain responsive to emerging challenges and innovations within the review period?

Removing the expiry date also extends the regulations indefinitely. Have the Government assessed the potential long-term impacts of this permanency on service providers and the CQC’s regulatory capacity? I think the noble Baroness knows why this question is being asked. Although I heard what she said about the operational issues that the CQC is undergoing at the moment, the regulatory changes that we are discussing may have some operational impact on the CQC.

In particular at the moment, when the CQC’s backlog is significant and its chief executive has said that it has no idea how it will deal with it—indeed, there are certain things stuck in the computer system that they do not know how to get out—how will the Government ensure in the interim that any application made to the CQC regarding this instrument is dealt with in a timely and safe manner?

Finally, on the policy areas that the Minister said were outwith these regulations due to further consultation and the sensitivity required, when will the statutory instrument be laid before Parliament? What is the timescale? Are any interim measures being put in place to ensure that any safety issues or regulatory issues with these sporting events are dealt with before the statutory instrument is laid before Parliament?

With those questions, we are, as I say, very supportive of this instrument in a broad sense, but the Minister’s normal detailed response would be welcome.

[Lord Kamall (Con)]

My Lords, I once again thank the Minister for the statutory instrument before us. We understand the reason for it: making sure, in particular, that this continues to be in effect after March this year, and setting the next review for 2028. Maybe that is where some of the questions arise—the noble Lord, Lord Scriven, alluded to some of these concerns.

We have just finished debating an SI on adapting for innovation—particularly in relation to speeding up clinical trials, which is to be welcomed. It showed that we need to be flexible with the emergence of new technology, knowledge and capabilities in health and social care. But, like the noble Lord, Lord Scriven, we wonder about a five-year review cycle, which may not allow for sufficient flexibility, given some of the fast-paced developments in healthcare. We have seen massive strides in digital health and mental health services. In our debate earlier in the Chamber, we asked about the use of AI in analysing data that the NHS already has. Will five years be too long to wait? Could it slow down the adoption or reviews, if you like, of some of these new technologies? Could the delay in reviewing regulations lead to some important issues being unaddressed for far too long? There may be new awareness of some emerging patient safety risks, for example. I just wonder: how do we get the right balance? I understand why the Government have extended this for five years, but we want to make sure that, within those five years, the Government, the NHS, the regulations and the CQC are flexible enough to take account of innovations.

The absence of interim mechanisms for addressing pressing issues during this review period could also foster a sense of regulatory stagnation. There may well be a case where providers and stakeholders feel that concerns are not being acted on quickly enough, especially as challenges arise before that next review. Although we understand the need for a stable framework, we want to understand how to get the balance between stability and responsiveness right. Could that delay necessary regulatory adjustments?

The other point here is extending the scope of the regulations to all patients being assessed or treated for a mental health disorder in a mental health unit. Obviously, this coincides with the debate that noble Lords are having on the Mental Health Bill. In this case, it extends beyond only those with learning disabilities and autism. This expansion is generally welcomed, but, once again, it raises questions—which were raised on the last SI—about resources and capacity. I know that the Minister has heard this a number of times, particularly during the passage of the Mental Health Bill. Will there be sufficient support for providers so that they can meet these expanded requirements? How will the Government monitor and address any challenges that may arise from this broader scope?

Fortunately, the Minister pre-empted one of the questions that I was going to ask about the regulations’ provisions on temporary healthcare settings, particularly at large sporting and cultural events. We understand the need to remove those regulations, but what thought has been given to the unintended consequences of doing so? I am generally supportive of removing regulations, but I understand why we need them: to make sure that enough account is taken of safety but also that someone is held responsible and there is some accountability when things go wrong.

--- Later in debate ---

[Baroness Merron (Lab)]

I thank noble Lords for their thoughtful contributions and questions. The summary of the noble Lord, Lord Kamall, of what we are looking for is exactly right. It is all about balance: we need efficiency and speed, but it has to be right. I certainly share that view. As I set out in my opening remarks, the dual purpose of this SI is to remove the expiry date of the 2014 regs and to amend the five-year period from which they should be reviewed. As I mentioned, this is to ensure that health and care providers will continue to be required to register with the CQC and comply with the fundamental standards set out in the 2014 regulations after 31 March this year, and also, as we all agree, to ensure that services will continue to be required to provide a safe and high-quality standard of care.

I turn to the points raised by noble Lords. If I find, on review, that I have not adequately answered or have inadvertently missed any questions, I will of course write with the requisite information.

The noble Lord, Lord Scriven, referred to the post-implementation review of the 2014 regs. That review ran from May to July 2022, and there were 86 responses. Interestingly, there was insufficient evidence in the responses to suggest whether the objectives of the 2014 regulations remain appropriate and whether there is an alternative system of regulation that would impose less regulation on the health and social care sector. I think we can safely say that it was not conclusive in pointing us in a particular direction.

The noble Lord, Lord Scriven, also asked when the statutory instrument to remove the exemption relating to the regulation of medical care at temporary cultural and sporting events will be laid. I can say to him that it will be in the summer.

The noble Lord, Lord Scriven, also raised the question of the performance of the CQC, which I completely understand. He asked what is happening, how we are dealing with the backlog of registrations and what is our assessment of its long-term impact on regulatory capacity. I understand that. I re-emphasise that the chief executive of the CQC has commissioned an independent review to look specifically at the CQC’s technology. That will help reduce the backlog, which can be tracked back to 2023, when there were a number of difficulties that now need to be resolved. I absolutely agree that the backlog in registrations is a problem particularly for small providers trying to set up a new care home or service. That problem can mean lost revenues and investment, and that has a knock-on impact on capacity, which we very much need to expand.

[Lord Scriven (LD)]

It is really helpful that the Minister says that, but a review in itself does not solve the problem. Have the Government given the CQC a timescale, not just regarding a review but for when they expect the operational difficulties to have been addressed? It is important for those who are registering to understand that. What is the timescale, not for the review but for dealing with the consequences of the backlog?

[Baroness Merron (Lab)]

The noble Lord has raised this with me in the Chamber and in a Parliamentary Question, if I am not mistaken. While I cannot be specific, as I have mentioned before, the fortnightly meetings with CQC—after which a report also goes to the Secretary of State—are an example of focus which, I hope, give some sense of the pace and intensity in putting this right. The CQC not being fit for purpose is an unsustainable situation which is causing great difficulty. When I can update your Lordships’ House about timelines, I will be very pleased to do so.

The noble Lord, Lord Kamall, asked about interim plans being in place. This is kept under review. We are working with the CQC on its recovery and will review whether further changes are needed. There is nothing to stop us from reviewing regulations in the interim. Five years is the statutory requirement, but it does not mean that we cannot act sooner. It is a point well made about time. Similarly, the noble Lord asked whether the reviews being every five years would slow down the adoption of technology. The intention is that it would absolutely not. The reason for keeping the regulations under review is that that would not be regarded as getting the right balance which we all seek.

Regarding capacity issues to meet the expanding requirement, we are very conscious of the consequences. The Government will work with the CQC, NHSE and its partners on a workable mechanism for notifying restraint within 72 hours, which was the point raised.

With that, I thank noble Lords for their contributions. Perhaps I can assure them that, in some ways, this is for me a work in progress, on many sides. We will continue to do that.

Valdo Calocane: NHS England Report

Lord Scriven Excerpts

Thursday 6th February 2025 Lords Chamber

[Baroness Merron (Lab)]

I assure the noble Lord that officials are working with NHS England and partners to set out the next steps regarding how future mental health homicide reports should be published and to ensure that we act as transparently as possible in line with our legal obligations and with engagement for families. That is very important for the future. The three points the noble Lord raises are very relevant and are being dealt with thoroughly in Committee as we take the Mental Health Bill through this House. I am confident that your Lordships’ House is on top of this matter, as are the department and all concerned. There has already been progress on the CQC report published previously, and all the recommendations in this report have been accepted in full.

[Lord Scriven (LD)]

My Lords, these Benches share in the condolences to all those affected by this tragedy. This is a watershed moment, but I am not sure whether the culture of the NHS has changed, given that yesterday a senior official said,

“the system got it wrong”.

No. Individuals in the system got it wrong. What extra mechanisms will the Government put in place to ensure that every individual is held accountable for this and future tragedies in each ICB area?

[Baroness Merron (Lab)]

I understand the seriousness of the points the noble Lord makes. As he is aware, the report to which we are referring is concerned with the care and treatment provided by health services to Valdo Calocane rather than questions of culpability. More broadly, I remind your Lordships’ House that the Prime Minister has committed to establishing a judge-led inquiry into these attacks. We absolutely understand the importance of an inquiry. Having met the families myself, it is crucial to provide families with answers and ensure that this cannot happen in the future.

Care Homes: Safety Ratings

Lord Scriven Excerpts

Wednesday 5th February 2025 Lords Chamber

[Baroness Merron (Lab)]

To take the second question first, the commission will start its work in April. The noble Baroness, Lady Casey, has agreed to lead that review. The terms of reference will be published, and the first report will be with us next year. On the important point about IT, as I mentioned in response to the noble Lord, Lord Patel, that problem arose in 2023. The CQC has acknowledged, as we have, that there have been huge challenges with the provider portal and the regulatory platform. The Dash review talked about poorly performing systems hampering ability. This is not how the system should work. As we move towards the 10-year plan, and from analogue to digital, we will have that front and centre in how we work.

[Lord Scriven (LD)]

My Lords, the Secretary of State in July said that

“the CQC is not fit for purpose”.

Given the systematic failings still within that organisation, what timescale have the Government given the CQC to become fit for purpose?

[Baroness Merron (Lab)]

The Secretary of State did indeed say that, and he was right to do so, in the spirit of transparency. The fortnightly meetings which I mentioned will be a constant assessment until we have met the necessary timeframes that are only reasonable to assist people in making decisions. All of that—how might I put it?—deep focus on the CQC will continue. I do not think this will be quick, but it will be thorough.

New Hospital Programme Review

Lord Scriven Excerpts

Tuesday 28th January 2025 Lords Chamber

[Lord Kamall (Con)]

My Lords, when we have Statements such as this, it is easy to fall into the old-fashioned debate of the Opposition condemning the Government for every change to policy that they announce, and the current Government blaming the previous Government. I hope that the Minister will appreciate that, as the shadow Health Minister, I have tried to act in a more constructive manner—I see her nod—by supporting the Government when we agree, and by asking questions to understand their reasoning and ambitions.

We all want a system of health and care that is fit for the future, fit for today and patient-focused. We welcome the Government’s focus on their three principles. I shall not test the Minister on them, because I know that she can reel them off. They are: hospital to community, analogue to digital and sickness to prevention. Indeed, when I was a Minister in the department, part of my job was to push the digital agenda in health and care.

With that, I am equally sure the Minister also welcomed the opening in April last year of the new Dyson Cancer Centre in Bath, as well as the completion of the Greater Manchester Major Trauma Hospital in May 2024. We are disappointed that the Government have delayed the new hospital programme, and it was also disappointing to see the Secretary of State criticising some of the aspects of the new hospital programme.

We completely understand that the Government have felt it necessary to reassess the timeline for delivering the hospital building programme, but may I press the Minister on those changes? Having delayed some of these new hospitals and the rebuilding of existing hospitals, are the Government still committed to building the same hospitals on the same sites? Is there a possibility that they will change the criteria for where the hospitals will be built?

We also want to understand how this fits into the Government’s other ambitions. The Government are committed to building 1.5 million new homes. Where these new houses are concentrated will inevitably create new areas of pressure on health and care services. Will the Government be considering the impact of their housebuilding targets on the location of these new hospitals, and will that affect the hospital programme?

I have one final point. Brand new, state-of-the-art, large-scale hospitals are all well and good, and we certainly need more hospital capacity, but I know the Minister will agree that they should be supplemented by an increase in primary care facilities. I know the Government have committed to doing just that. The noble Lord, Lord Darzi, was unequivocal in his support of this in his recent report. Have the Government allocated funding for new primary care centres, such as the one mentioned by the Minister in Oral Questions today, and community health and care centres that could offer some secondary care services, taking pressure off the hospitals, but also better rehabilitation for people in their local community, also taking pressure off the larger hospitals? I look forward to the Minister’s responses.

[Lord Scriven (LD)]

My Lords, I extend my gratitude to the Minister for the Statement on the pressing issue surrounding the new hospital programme review. This initiative, inherited from the previous Conservative Government, who overpromised and underfunded, was a significant letdown for countless communities and patients across England. While the ambition to modernise hospital infrastructure is commendable, the current trajectory raises serious concerns that demand urgent attention.

Such concern was raised in a recent email from the chief executive of Leeds Teaching Hospitals NHS Trust, which showed the impact on both patients and staff of such a delay for capital investment in the hospitals that he leads. Recent data paints a worrying picture: hospitals facing delays under the new hospital programme reported over 500 infrastructure-related incidents in the past year alone. These failures led to the loss of 32 days of clinical time, directly impacting patient care.

This is not just about numbers, it is about real people unable to recover, return to work or resume their daily lives because of these delays. Alarmingly, nearly 100 flooding events occurred in these hospitals that have now been delayed for repair and rebuilding, representing a quarter of all such incidents across NHS England, despite these hospitals accounting for less than 1% of the total NHS estate. Helen Morgan MP, the Liberal Democrat spokesperson in the other place, aptly described these hospitals as “hanging by a thread”. She rightly criticised postponement of essential projects as a “false economy” that jeopardises patient safety. Delays not only inflate cost, forcing hospitals to allocate more of their stretched budgets to essential maintenance, but allow estates to deteriorate further, leading to closed clinics and clinical facilities, extending waiting times and possibly leading to poorer health outcomes for patients.

Therefore, I ask the Minister: have the Government conducted an impact assessment of these delays? If so, will she release a comprehensive evaluation detailing the risk to patients’ well-being, the additional maintenance cost anticipated between now and 2039 for these hospitals, and the financial implications of delaying investment? Specifically, have the Government considered whether to adopt an invest-to-save model, offsetting the cost of borrowing against the escalating maintenance burden and the economic inactivity for some patients caused by estate failures? This could provide a more sustainable way of building these hospitals.

The Autumn Budget of 2024 announced a £3.1 billion increase in the health and social care capital budget over the next two years. While welcome, this figure falls far short of the £6.4 billion per year experts say is necessary to address the NHS’s growing challenge. Over recent years, the maintenance backlog has more than doubled in real terms, rising from £6.4 billion in 2015-16 to a staggering £13.8 billion in 2023-24. This includes urgent issues such as crumbling roofs, outdated electrical systems and failing heating and ventilation—conditions that no hospital staff or members of the public should endure.

The King’s Fund has highlighted a troubling practice. Despite planned increases in capital investment, financial pressures have driven the reallocation of capital budgets to cover day-to-day spending. This undermines the long- term investment urgently needed to maintain and upgrade our healthcare facilities. In light of these alarming facts, I pose the following questions to the Minister. What specific measures have been implemented to ensure that delays to hospital building programmes do not compromise patient safety? How do the Government plan to bridge the gap between the £3.1 billion and the £6.4 billion per year experts say is required to address the NHS hospital maintenance backlog? Will the Government publish a detailed impact assessment of the delayed projects, outlining the risk to patient care and safety? What strategies have been put in place to ring-fence capital budgets, ensuring they are not diverted to cover day-to-day expenses? How do the Government intend to address critical maintenance issues, such as failing roofs and outdated electrical systems in hospitals that will not see rebuilding until the mid to late 2030s?

In conclusion, while the Government’s commitment to improving hospital infrastructure is evident, the current capital allocations are insufficient to address the pressing needs of these facilities. Without sustained investment, the Government risk compromising both patient safety and quality of care. I urge the Government to reassess their funding priorities and consider an invest-to-save model to secure safe and effective hospital environments for patients and professional staff alike. I call on the Minister to address these concerns with the seriousness that they deserve.

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

My Lords, I am grateful for the reflections and questions from the Opposition Front Benches, although I noticed a difference in the level of understanding of where we are between the noble Lord, Lord Scriven, and the noble Lord, Lord Kamall—I note his disappointment with what he refers to delay and reassessment, and I will return to that.

Perhaps I might make a few points that might be helpful to frame some of the responses, and then go on to some of the specific questions that were asked. I note the disappointment of the noble Lord, Lord Kamall. I cannot, however, accept his assessment, because of where we started. It is impossible to ignore that. As we know, the independent investigation by the noble Lord, Lord Darzi, found the NHS to be starved of capital—indeed, the noble Lord, Lord Scriven, spoke to that. There was some £37 billion of underinvestment in the 2010s, and the fact is—this is borne out by the National Audit Office, which confirmed it—that we were not going to be seeing 40 new hospitals by the date set, so, in my view, it has been independently verified. The new hospital programme was announced by the last Government in October 2020 to deliver 40 new hospitals by 2030. The fact is the schedule for delivery was repeatedly delayed and, on top of that, unfunded beyond March 2025.

That is why, when we came into government, the Secretary of State within weeks commissioned an urgent review into the new hospitals programme. That, I am glad to say, was carried out at pace over the summer of 2024. What was that all about? It aimed to put the programme on a firm footing with sustainable funding. I do not accept that that was simply a delay. I can understand disappointment—I would like it to be different—but we have been dealt the hand we have. The outcome of the review, which was announced on 20 January in the Statement that we are discussing tonight, provided a credible plan and timeline to deliver schemes, and that is set out in the published New Hospital Programme: Plan for Implementation. It is backed with investment, which is expected to increase to £15 billion over each consecutive five-year wave. That is averaging around £3 billion a year from 2030. Funding will, of course, as with all government funding, be confirmed at future spending reviews.

The current wave of new building is under way, and there are a further three waves. The first wave consists of 16 schemes beginning construction between 2025 and 2030; wave 2 has nine schemes beginning construction between 2030 and 2035; and wave 3 has nine schemes beginning construction between 2035 and 2039. That is like chalk and cheese compared with where we were before. We had a promise of new hospitals when, in fact, many of them were not new hospitals, whereas this sets out quite clearly what will be built, when it will be built and the funding. To me, this is actually honesty; it may not be where we want to be, but it is saying that this is the honest situation, and this is what we will do.

The new hospital programme provides a mix of new builds and/or refurbishments, new-build extensions and refurbs. That is under that programme, and I can also confirm to the noble Lords that we will be appointing a programme delivery partner in the coming weeks to support this delivery.

I was asked about other capital projects, and I shall just mention a few. Capital spending is increasing this year, rising to £13.6 billion next year. That includes £1.5 billion for new surgical hubs, diagnostic scanners, beds across the estate and new radiotherapy machines to improve cancer treatment. That will also help greatly towards tackling waiting lists.

Reinforced autoclaved aerated concrete, or RAAC, is an area of great concern. Over £1 billion has been allocated to tackle that and address the backlog of critical maintenance, repairs and upgrades across the NHS estate, to which the noble Lord, Lord Scriven, referred. Importantly—because we often discuss this—over £2 billion will be invested in NHS technology and digital infrastructure, because it is not just physical build but about making sure that we are building for the future.

In general terms, I believe that the new hospital programme is finally, as it was not before, on a sustainable footing. The plan is realistic, credible and transparent, so we will be held to account. It is part of our determination to rebuild the NHS and rebuild trust—because I feel, sadly, that trust went.

The noble Lord, Lord Kamall, rightly raised the point that it is not all about large-scale hospitals, and I certainly agree with that—not least because it is one of our pillars, as the noble Lord said, to shift the focus of the NHS out of hospitals and into the communities. We understand that, if patients cannot get a GP appointment, for example, they are going to end up in A&E, which is worse for them and expensive for the taxpayer. At the Autumn Budget, we established a dedicated—and I stress “dedicated” in answer to the question about funding from the noble Lord, Lord Scriven—capital fund of £102 million for 2025-26 to deliver around 200 upgrades to GP surgeries across England that will support the improved use of existing buildings and space, boost productivity and enable the delivery of more appointments. I would absolutely agree that that is very important.

I was asked about other funding, and I have mentioned the health capital spending that is needed. I say to the noble Lord, Lord Scriven—and I know he is aware of this—that we inherited a monumental backlog of maintenance. I refer also to a couple of other points that the noble Lord raised. I do not want to put words into his mouth, but one of them was about whether we can review. I know that this is an issue, and there are certain schemes that people wish to advocate for and are particularly concerned about. The fact is that the decisions have been made, and they were made while taking into account all the necessary criteria in a fair and open way. The Statement outlines the lists, and they will not be changing. For those who are not on the waves, we are working with them to look at what is needed, so people are not being ignored. I also emphasise that my colleagues in the House of Commons, the Secretary of State and, particularly, the Minister, Karin Smyth, have engaged widely and very quickly with every constituency MP, in the waves that are outlined in the Statement and those that are not mentioned, because we understand people’s concern.

The noble Lord, Lord Scriven, also asked about an assessment of the impact of the new delivery schedule. It is now available on GOV.UK with the plan for implementation— and I hope that is helpful. I definitely echo the noble Lord’s concerns about continuous switches between capital and revenue, and I can assure him and your Lordships’ House that the Government’s now updated fiscal rules will stop future switches from capital to revenue. I also reassure both noble Lords that the Government are committed to all hospitals in the new hospital programme. No scheme has been added or removed, and we are working with each trust in the programme to determine the most appropriate site in line with local needs and the needs of the individual scheme.

If I may make just one last point, the noble Lord, Lord Scriven, asked about consideration of invest to save, and I have to say that the Statement outlines exactly how we will proceed in this regard.

We know that we have to underline the under- capitalisation of the past; that is essential if we are going to fix the foundations of the NHS and if we are going to make it fit for the future. I hope that noble Lords will accept that this Statement represents a change. It is deliverable, manageable, transparent and will provide what it says it will do on the tin.

Mental Health Bill [HL]

Lord Scriven Excerpts

Committee stage
Monday 27th January 2025 Lords Chamber

[Lord Bradley (Lab)]

My Lords, in moving Amendment 128C I will speak also to Amendment 163C in my name. These amendments relate to Clause 47, “Remand for a person’s own protection etc”, and Clause 53, “Commencement”. I will speak very briefly, because the purpose of these two interlinked amendments is substantially the same as the ones we just discussed: Amendments 128A and 163B. However, they stress that remand should always be part of our deliberations when we are talking about people who may find themselves in the criminal justice system.

Amendment 163C would require that Clause 47 comes into force no later than 12 months after the passing of the Bill. Amendment 128C would require the Government to publish a report on effective implementation of Clause 47. These two amendments encapsulate the need to make really rapid progress to ensure that there are adequate community alternatives and community health-based provision to support people who may be placed on remand, where the sole concern is the defendant’s mental health.

We have to ensure that these facilities are geographically spread across the country. We also have to ensure that we can see bail being used in a way that is commensurate with people who may have found themselves going to a place of safety, but with the same support required for their continued treatment as if they were already within the criminal justice system.

With that, I am happy to listen to a positive response from the Minister. I beg to move.

[Lord Scriven (LD)]

My Lords, I will be very brief because of the time. As with the previous group of amendments from the noble Lord, Lord Bradley, we are very supportive of the intention to try to tease out of government what the implementation plans are. It is really important to understand that being supportive of Clause 47 does not necessarily mean that we believe it will come into implementation in a timely fashion.

By supporting the noble Lord’s amendments, we wish to tease out of government the exact timing and resources that have been allocated; the planning the Government will have to do in terms of the number of provisions that will be required to implement this clause; the gap between the number of those facilities in place and those needed; and the estimate the Government have of when they would seek to put those facilities in place.

As the noble Lord, Lord Bradley, said, the location of those facilities—where there are gaps geographically and where they need to be filled—is very important. It is important that the Government furnish the Committee with those details so that we can fully understand not just the intention of implementation but the scale of the implementation plan required for this clause.

[Lord Kamall (Con)]

My Lords, just like in the last group, I will speak to and support the amendments in the name of the noble Lord, Lord Bradley. They follow the amendments in the previous group.

These Benches welcome Clause 47—another positive move—which addresses the issues arising from the current situation. As the noble Lord, Lord Bradley, said, bail can be refused solely on the basis of a mental health condition where it might otherwise have been granted.

In simple terms, as the noble Lord, Lord Scriven, said, this amendment returns to the theme that he, and many other noble Lords, have pushed the Government on—and I like the words used by the noble Lord—to “tease out” the plan and timetable for implementation from the Government, since it requires the Secretary of State to prepare a report on how they plan to implement these changes within the time period proposed in Amendment 163C.

We have to remember that the impact assessment states, in regard to the changes to remand for a person’s own protection, that:

“Departments are working together to ensure there are clear pathways and provision in place to safely enact these reforms and the timeline for implementation will depend on the conclusion of this work”.


That has been manifested this evening with the presence of a Minister from the Department of Health and Social Care and a Minister from the Ministry of Justice. However, there is currently no set date for the commencement of Clause 46, so it is all contingent on internal departmental assessments. We all understand how government works—how long it takes for things to happen, to get write-round and to get support across government—so I gently suggest to the Minister that the 12-month implementation timeline would be a useful target for the Government to work towards. It could help them to answer some of the questions that many noble Lords have asked in Committee on the plans for, and stages of, implementation. That is not to force the Government to move faster than they want to go, but just for us to understand the various milestones along the way in developing what is in the Bill.

It would also be helpful if the Minister could set out how much progress has been made both in the Ministry of Justice and the Department of Health and Social Care on establishing the pathways and processes to enable these remand reforms to go forward. This is especially true since the impact assessment also states—this is quite an interesting point—that:

“We expect the number of people on remand solely for mental health reasons to be low and therefore health and justice costs relating to this change are likely to be negligible, and therefore have not been monetised”.


We understand the challenges that the Government are often talking about—they have to wait for spending reviews, et cetera—but the impact assessment states that the number of people affected will be low. Can the Minister say whether either his department or the Department of Health and Social Care know what that means and how many people that will be? Does he know how many will be impacted by this change? If he accepts what is in the impact assessment—that the costs will be negligible—this could be a quick win for the Government in relative terms, depending of course on what other processes he feels have to be put in place before they can deliver this. I hope that the Minister can be a bit more helpful on his noble friend’s amendments, given that the costs are low.

We look forward to the Minister’s response, and I would be grateful if he could give an indicative timeframe or an indication of when a timeframe will be in place.

--- Later in debate ---

I hope that the noble Lord, Lord Scriven, is content with my reply about timing and the information that I will be able to give to noble Lords in due course. I hope this also reassures the noble Lord, Lord Bradley, that we intend to implement the reforms to the Bail Act as soon as it is safe to do so. I therefore urge him to withdraw his amendment.

[Lord Scriven (LD)]

The noble Lord, Lord Kamall, quite rightly pointed out that the impact assessment says that the Government have already said that the numbers will be small and the costs negligible. Upon what data were those assumptions from the impact assessment made? If the Minister cannot give me the answer to that at the moment, could he provide the Committee with the detailed figures and data used to present that within the impact assessment?

[Lord Timpson (Lab)]

I thank the noble Lord for his question. I will be delighted to get the correct information, so that we get it exactly right. We will get it to him as soon as is practical.

Mental Health Bill [HL]

Lord Scriven Excerpts

Committee stage
Monday 27th January 2025 Lords Chamber

[Lord Timpson (Lab)]

I thank the noble Baroness for the question. One of the questions that I have been asking colleagues is on exactly this point around whether this will happen. I have been reassured by asking policy colleagues many probing questions that the points in the Bill make it as tight as possible without conflicting professionals in the way they are going about their role.

[Lord Scriven (LD)]

I welcome the Minister to his first Committee. Clearly, a lot of work has been done on this to work out within 18 months what is required. Will the Minister let the Committee know what the gap is between existing provision and what would be required in terms of beds and staffing for this 28-day provision to come into force? That is an important piece of information that the Committee needs to understand to see whether it is just an aspiration or there are the resources needed to make it real.

[Lord Timpson (Lab)]

I will ask officials to get me that information and to pass it on.

--- Later in debate ---

[Baroness Merron (Lab)]

The noble Baroness makes a good point. I am sure she is aware that one of the main pillars of change as we move towards the 10-year plan is shifting from analogue to digital. I am sure that this will be part of those considerations.

I now turn to Amendment 121, tabled by my noble friend Lord Davies of Brixton and supported by the noble Baronesses, Lady Tyler and Lady Neuberger. The noble Baroness, Lady Tyler, spoke to this very amendment. We know that financial problems can worsen or trigger mental illness. We agree that individuals should be encouraged to include in their ACD any care and support to help them manage their financial circumstances when unwell. The code of practice will include guidance from professionals on this point, while the template will prompt people to consider financial matters.

On Amendment 122, tabled by the noble Baroness, Lady Browning, and supported by the noble Lord, Lord Patel, it is important for practitioners to be aware of, and, where applicable, to consult with, the person’s attorney. However, we do not agree with requiring people to include all of the information contained in the lasting power of attorney in their ACD. The document is owned by the individual, who should be free to include what matters to them. Some of the information in a person’s lasting power of attorney may not be relevant, and copying over its contents may introduce inaccuracies due to human error. We intend to encourage service users to include the existence of an LPA where applicable in their advance choice documents, and practitioners can then be made aware and take the relevant steps.

On Amendment 123, tabled by the noble Baroness, Lady Browning, we agree with the aim that is stated here. The code of practice will set out all of the groups which services should proactively target to make an advance choice document, including people on the dynamic support register. The code can be updated in line with emerging research and best practice, as I have said a number of times before, and can include detail and nuance that is not possible in primary legislation.

With those remarks from me in mind, I hope that noble Lords will feel able not to press their amendments.

[Lord Scriven (LD)]

I have one very quick question. Throughout the whole of Committee, since day one, the Minister has referred to the code of practice being updated. Can she tell us the date by which it will have been updated? It is quite important for implementation and some dates that the Minister keeps referring to. If she cannot let us know now, she could write to the Committee.

Mental Health Bill [HL]

Lord Scriven Excerpts

Committee stage
Wednesday 22nd January 2025 Lords Chamber

[Lord Scriven (LD)]

I think one of the reasons why people are asking for an open and transparent review—and, in some cases, one that reports back to Parliament—is that this is about not only the data but accountability for carrying out actions and implementation. That is the bit that is missing. Everything I have heard from the Minister on this subject so far—maybe she is coming on to say something else—suggests that without accountability, and overview and transparency of that accountability, the guidance is not going to work. Believe me, as somebody who used to work in the service: if you know that the Government were looking at this and that it was going to Parliament, it sends a powerful message for action to be taken in each individual unit. That is what is required, and I do not see that coming from the Minister’s answers. Can she tell me where that accountability streak will be, and how we, in this House and the other House, can put pressure on if the guidance is not being followed, based on the process she has outlined?

[Baroness Merron (Lab)]

I understand the point the noble Lord makes. However, it does not lead me to accept the amendments. I understand the intent and I am sure noble Lords realise how sympathetic I am to it, but I repeat the point I made earlier: if one looks at what the amendment actually does, it will not serve that purpose. I take the point about transparency and accountability, and I hope the noble Lord has heard many times that that is very much the mode of direction. Perhaps it will be of some assistance to say that the PCREF will improve data collection on racial disparities over the coming year, and the CQC has existing duties to monitor and report on inequalities under the Act. We will continue to monitor racial disparities in the use of CTOs. That situation will be ongoing. If it is not doing the job that it is meant to do, we will not be complacent and will seek to act.

We agree there is a need to improve organisational leadership—

[Baroness Merron (Lab)]

The noble Baroness is quite right: one has to be able to compare, and that baseline will be in place. You could collect all the data you like, but it has to be meaningful. Her point is well made.

There is a need to improve organisational leadership to improve data collection and change culture across the mental health system. Again, this is exactly what the PCREF is designed to do and something we want to embed further through the revised code of practice.

The creation of a responsible person was an additional recommendation from the pre-legislative scrutiny committee, and it is one we have considered in some detail. However, ultimately, we think that the role is not necessary, because it would duplicate existing roles and duties. There are already duties on providers of mental health services to identify and address inequalities relating to protected characteristics under the Equality Act 2010 and specifically the public sector equality duty. CQC already has a duty under the Mental Health Act to monitor as health services exercise their powers and discharge their duties when patients are detained in hospital or are subject to CTOs or guardianship. It publishes an annual report, Monitoring the Mental Health Act, which includes detailed commentary on inequalities. The PCREF is now part of the NHS standard contract. It has created new contractual obligations on providers to ensure that they have a framework in place to record and address racial inequality in mental health systems and to look at training and other policies to address racial disparities. Ultimately, we do not think that a responsible person is necessary to achieve all the aims, which are understood, set out in the amendment.

Finally, I want to turn to Amendment 138 tabled by the noble Lord, Lord Kamall, and supported by the noble Earl, Lord Howe. We recognise, as I have said, that there are significant inequalities in the use of detention under the Mental Health Act and of CTOs between different minority-ethnic groups, and in particular the overrepresentation of black men. We monitor those inequalities through routinely published data and are improving this data through the PCREF. The CQC, as I have mentioned, reports on inequalities in its annual report under existing duties, but we agree that we lack robust evidence on what drives those inequalities, and that has been a matter of considerable debate in your Lordships’ House. We need to conduct research into this, and we are exploring with experts, including academic researchers, the best way to tackle it.

I am concerned that two years is not enough time to scope and commission the report, collect and analyse new data, and form meaningful recommendations. Additionally, we hope that through improved decision-making under the reforms we will see a reduction in the number and proportion of black men who are subject to the Act and a reduction in racial disparities more generally. It is a major driver of why we introduced the Mental Health Bill. A report after two years feels premature, because it would be likely to be based in reality on data from before the reforms were commenced.

[Lord Scriven (LD)]

I am grateful to the noble Baroness for giving way and sorry for interrupting her flow again. The point about having a staging report after two years is to get ahead and upstream of what is happening rather than retrospectively being able to do stuff after it has gone on. Two years in management terms to be able to determine trends of intended or unintended consequences and then put different things in place is really important. I believe that this amendment, with a report back to Parliament, would send a very strong signal and allow the Government, the department and NHS England to pick up trends, even if it was not the total picture, which would determine different policies and practices and potential changes in the code as well as management action. I think that is what lies behind the noble Lord’s amendment.

[Lord Kamall (Con)]

I am sorry to interrupt at this time. I note that the noble Baroness thinks that 12 months is too short, and many noble Lords can perhaps see the point that two years is too short. Does the department have any idea of what a reasonable timeframe is? There has to be some accountability, as the noble Lord, Lord Scriven, said. We could accept the warm words and the intentions of the Minister here tonight, but what happens if nothing changes? Where is the accountability? Can the Minister think about asking the department whether there is a reasonable timeframe for some meaningful research? I have supervised academic theses over time. You can have the one-year and then you go on to the three-year for PhD, and sometimes that is quite comprehensive data. There might be a meta study that could be done of lots of existing studies. First, what is a reasonable time? The noble Baroness does not have to answer now; it can be in writing. Secondly, if we let this go, how do we make sure there is accountability? How do we come back to this in three years or four years or five years? I look forward to the answer.

Mental Health Bill [HL]

Lord Scriven Excerpts

Committee stage
Wednesday 22nd January 2025 Lords Chamber

[Baroness Bennett of Manor Castle (GP)]

My Lords, I will be brief, but in following the noble Baroness, Lady Fox of Buckley, I have to note that I do not believe that a complaints culture is a problem in the contexts covered by this Bill. There is, perhaps, a lack of listening to patients and those affected, and a lack of action rather than a problem with listening to complaints. In that context, I commend the noble Earl, Lord Howe, who cited extensive testimony from Blooming Change. One thing that struck me when looking back over the previous days of Committee was that it would have been good to hear, perhaps even more than we did, direct testimony and the voices of those who are experts by experience. The phrase “nothing about us without us” really stuck in my mind and it is important that we keep that in mind throughout Committee. Again in response to the noble Baroness, Lady Fox, I think it is important not to seek to downplay the mental health crisis that we are seeing across our society. There is a huge shortage of services meeting people’s very clear and acute needs, and acute needs are what we are largely covering in this Bill.

I attached my name to Amendments 50 and 51 tabled by the noble Baroness, Lady Tyler of Enfield, which address non-drug-based interventions. In essence, I agree with everything the noble Baroness said; I just want to stress her points. When we talk about non-drug-based therapies, we are tempted to think we mean talking therapies and psychological therapies. Those are tremendously important, but this is where we also need to take the broader public health context. I mentioned on an earlier group digital treatments such as Avatar for those who hear voices. They are the kind of new, different ways of looking at things that people may not have been trained in, and it is important that they are considered. I also talked a fair bit about the gut-brain axis and dietary interventions such as green prescribing, in which we have seen great advances across the medical fields in recent years—exposure to green spaces and the chance to get exercise in green spaces. That makes me think that we need to think about facilities and how we make sure there is provision within them, which, in some ways, this amendment would help to cover.

As a noble Lord said earlier, we are talking about making sure we are treating the whole person and not a condition with a drug. I thought the contribution from the noble Lord, Lord Crisp, was very important, as is his amendment. I am not sure whether it needs to be in the Bill, but it would be interesting to have the Minister’s comments on making sure that consideration of withdrawal symptoms is part of prescribing practice. That is absolutely key and central. I note a report from the universities of Berlin and Cologne out last year which showed that the second-most prescribed antidepressant in the UK, venlafaxine, also has the second-highest rate of problem withdrawal symptoms. We need to make sure that is carefully considered pre-stage—before we get to the withdrawal stage, are we going to create that problem? I do not know whether it could be incorporated in the amendment, but it is something to think about anyway.

The other amendment—slightly oddly—in this group in my name is Amendment 154, which again, as on a previous group, I put down at the request of the Law Society. It is about mental health tribunal pilots for challenges against treatment decisions. To some degree, we have already discussed this in the earlier group, but I would be interested in whether the Minister has any comment on the amendment. I think that it is fairly self-explanatory, so I will not go through it further.

[Lord Scriven (LD)]

My Lords, I shall speak to Amendments 54A and 54B in my name, which are on a very narrow part of the treatment plan for individuals. Before I do that, let me say that I support the amendments in this group, particularly the general thrust of what been said; that is, that the automatic medical model must no longer be the default position and a much more social model must be added on to the medical model so that they complement each other.

Having said that, I listened very carefully to the noble Baroness, Lady Fox, but found it very difficult to understand what was required. She argued against the use of medication but then argued against quite a lot of the non-medicated issues. Her intervention was a bit confusing in terms of understanding what the importance was.

My amendments are predominantly about Clause 18, which is about the use of ECT. The clause allows for the emergency use of ECT based on a second medical opinion. The element I wish to speak to is the very wide Henry VIII power that the Government wish to give themselves in regulations to do away with the second medical opinion in an emergency. The Bill says:

“The appropriate national authority may by regulations amend this Act to provide for circumstances in which functions of a second opinion appointed doctor in relation to treatment falling within section 62ZA(1) may or must be carried out instead by the approved clinician in charge of the treatment in question”.


New Section 62ZB(3) then says:

“Regulations under this section may make … (a) provision subject to specified exceptions; (b) different provision for different cases; (c) transitional, consequential, incidental or supplemental provision”.


That is quite a wide Henry VIII power.

To prove that I really am Billy No-Mates and do not get out often on a cold night, I read the wonderful 10th report of this Session from the Delegated Powers and Regulatory Reform Committee, which makes exactly the same points but in more eloquent language. This is a very wide Henry VIII power, and the committee does not really understand why the Government are seeking—even though it is through the affirmative procedure—such wide powers in such broad language.

The committee said that it would expect the power to be drafted with significant limitations and a framework for when it could be used. My amendment seeks to do exactly that. It would not prevent the clinician in change from using ECT in an emergency case without referring to a second practitioner in certain circumstances, but the regulations would be within a framework laid out in Amendment 54B, that

“the treatment is immediately necessary to save the patient’s life … obtaining a second opinion would cause a delay that places the patient at a significant and imminent risk of death or serious physical harm, and … the treatment is reversible”.

The regulations would have to be written so that

“Any amendment made under subsection (1) must specify the exceptional nature of the circumstances in which the second opinion may be dispensed with”.


A report to Parliament on subsection (1) dispensations would also have to be made.

I believe, from reading the wise words of the Delegated Powers and Regulatory Reform Committee in its report, that it is important that the regulations have a framework, so that the Minister still has flexibility but is constrained by what is in the Bill. That is why I have spoken to this amendment.

[Baroness Murphy (CB)]

My Lords, I feel I must poke my nose in on these of amendments, even though I do not have an amendment. I support the noble Earl, Lord Howe, and his various amendments. I particularly like the amendment that would require children and their families to be asked the month after how it all went.

We are hearing described the appalling nature of many mental health services. It is not just children’s services. Although they may be a very good example, as many of them are not fit for purpose, we would get the same complaints and the same appalling state of affairs if we went around other mental health services across the country. It is heartbreaking. I truly believe that services have deteriorated since I practised in hospitals. People, including my former colleagues who are still practising, say that services are completely disorganised and not fit for purpose. We have known for 50 years that the social model of care was an appropriate model, and that you need psychological and social psychotherapeutic interventions, as well as any drugs that might be helpful. They are not going on because there is no availability anywhere.

We have known since at least the 1960s that patients with schizophrenia, for example, can benefit by being taught, one-to-one, about how to interact with people when they are recovering from an episode. That never happens, because we do not employ teachers in the NHS—we just do not do it. We do not employ the right sort of people and we do not have the right sort of facilities. When people are employed, there are so few of them that it is simply impossible to do what is necessary. I am not defending this, because there are some very good units—I am sure that there are some very good children’s and young people’s units—but they are not the norm anymore, and that is a very sad state of affairs.

Sadly, legislation through mental health Bills will not, unfortunately, solve the problem. What we are talking about is not only a fundamental change of culture and getting on with all the things that we know should be done; there needs to be investment and a totally different approach to mental health. All the things that we know should be done cannot be delivered by mental health legislation alone. I say that because we are trying to shove too much into the Bill and hoping for the best, but I do not think that it will work.

Later in the debate on these amendments, noble Lords moved away from talking about people who were very unwell and who need in-patient care to talking about this vast mass of people who are diagnosed with conditions where they cannot work. That is a whole new ball game. I agree with almost every word that the noble Baroness, Lady Fox, said, because there is no doubt that there is a massive overdiagnosis of things that are called “mental disorder”, when they are in fact distress and need a different sort of approach.

A young friend of mine—a gentleman who is now in his final years training as a maxillofacial surgeon—had a period of great distress because of family circumstances. He sat down on his own one evening and went to a website, “Diagnose yourself”. He rang me and said, “I’ve been diagnosed as having ADHD”. I cannot imagine anybody who is less likely to have ADHD than this young man, who is the most socially competent young man I know. This morning, my husband and I had a go on the website together—he did one test and I did another—and we both came up with the same result: “You probably have ADHD”. Well, maybe I am, folks, but I am not going to go on the Ritalin yet. There are a lot of websites that are utter rubbish and encourage people to pay money to see psychotherapists and other counsellors to see what the matter is with them, so that other people can put money in their pockets for doing not much.

That is the different end of the spectrum. When we are thinking about these things, we have to think about what the patient has. Is it something that can be diagnosed—heaven knows that colleagues here were very keen that we should have a diagnosis—or something at the other end of the spectrum? With the Mental Health Bill, we are talking about when you can detain people, take away their rights and say, “We are detaining you”, to treat them, and protect them from wrong treatment, bad doctoring and bad staff. That is what the Mental Health Act is for.

But I am afraid that it is not to do with any of this other stuff. We have to think through what really has to be in the Bill to protect the patients and the staff and what cannot go in there because it is not relevant to these issues.

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Lastly on this amendment, while we are committed to expanding access to independent mental health advocacy, we are also mindful of not overburdening the workforce. This amendment is likely to be resource intensive, as well as resulting in a significant deviation from the IMHA’s current role: to support people to understand and access their rights when detained.

[Lord Scriven (LD)]

The Minister has reeled off a very good list of what is already in place. Have the Government done an assessment to see exactly how that learning is ingrained and how effective it has been in changing mental health provision and mental health services? If not, could she please go back to her department to try to find that, and write to Members of the Committee so we can see that in writing?

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[Earl Howe (Con)]

I am grateful to the noble and learned Baroness. I hope it was implicit in what I said that I would look to this Bill to include an order-making power that would enable regulations to be laid in due course that would cover not only 16 or 17 year-olds but also those under 16, and Parliament would then approve them. No doubt this is a matter that we can discuss further after this, but I hope that the point of principle is clear, which I fully support, that this issue needs to be sorted through this Bill.

[Lord Scriven (LD)]

I have listened to the noble Earl’s argument carefully, and in principle I support what he is trying to do. The only problem with leaving the matter to a statutory instrument, rather than putting it on the face of the Bill, is that it is far easier for the Secretary of State to change that, even despite the will of Parliament, based on the way that Parliament works. Why could it not be on the face of the Bill, to give absolute certainty, rather than in a statutory instrument, which normally gives flexibility and powers to a Minister?

[Earl Howe (Con)]

There are two answers to that. First, it is generally unthinkable for a Government to lay regulations without first having consulted the relevant parties. Secondly, if we are honest, putting something on the face of a Bill is not the whole story; there would need to be proper clinical guidance published alongside that for practical purposes for hospitals and elsewhere.

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[Baroness Merron (Lab)]

The overall concern is as I have identified. Yes, indeed, as always, it is a complex area that we need to unpick, but our main concern has to be for the welfare of the young person. The concern about the amendment is that, inadvertently, it would work in the opposite direction.

To finish on Amendment 55—this might also be helpful to the noble Baroness, Lady Bennett—we are of the view that the Bill strikes the right balance between self-determination and responding to the needs and vulnerabilities of children and young people. For example, in the clinical checklist, many of the new treatment safeguards and provisions around care and treatment planning apply equally regardless of age and aim to ensure that treatment is more patient-led.

Amendment 56, tabled by the noble Earl, Lord Howe, and supported by the noble Lord, Lord Kamall, is somewhat similar to Amendment 55 in seeking to change the Mental Capacity Act to provide a mechanism by which children and young people can make an advance decision to refuse medical treatment for mental disorder. However, under Amendment 56, the child or young person’s advance decision would have legal weight only if they were detained under the Mental Health Act. As I have already discussed, while we recognise the principled position to extend the rights of adults to children, giving under-18s the right to make an advance decision to refuse treatment would conflict with a long- standing legal principle established by common law in the courts and codified in the Mental Capacity Act and would, therefore, mean that the amendment would not achieve its desired effect. This principle recognises that, in some serious cases, the courts, parents or those with parental responsibility may overrule the refusal of a child or young person, especially in cases where the child’s life is at risk.

I reassure noble Lords that we are nevertheless committed to giving children and young people a voice as far as possible when it comes to decisions about their care and treatment. I refer again to the example of the clinical checklist, which requires consideration of a patient’s wishes and feelings, including those expressed in advance.

[Lord Scriven (LD)]

What legal status does the checklist that the Minister keeps referring to actually have?

[Baroness Merron (Lab)]

I will come back to the noble Lord on that, and I thank him for asking the question.

I was about to refer to the noble Baroness, Lady Tyler. I may not be doing so in quite the right place, so I hope she will forgive me, but I do not want to lose this point. She asked what engagement we have had with the Department for Education. Our officials have engaged with DfE officials on the development of the Bill, including on the interaction between the Bill and the Children Act, which I know is of quite a lot of interest to noble Lords. We have also discussed questions around the statutory test with both the DfE and the Ministry of Justice, given that competency tests apply in wider children’s settings than mental health. I hope that is helpful.

Amendment 136, tabled by the noble Baroness, Lady Tyler, would require the Government to hold a review of whether a statutory test of competence should be introduced into the Mental Health Act for under-16s within a year of the Bill being passed. While we recognise that there are competing views about Gillick competency, it is nevertheless the established framework for determining competency for children. To introduce a statutory test for under-16s only under the Mental Health Act is likely to risk undermining Gillick, which remains the accepted competence test for under-16s across all settings, including reproductive health and children’s social care, and the wider legislative framework on matters related to children.

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[Lord Scriven (LD)]

It is useful, but it is therefore contradictory to what the Minister has just said. If the checklist is statutory and it is legally binding that it has to be followed, how would a young person in that checklist having a view about their care be different from an advance directive? That is the issue. The Minister said the other alternative is that a person under 18 or 16 can make a decision in relation to the medical checklist, and she has just said that the decisions are legally binding. Alternatively, is it that carrying out the process is legally statutorily binding but the views of somebody who is 16 on that list are not?

[Baroness Merron (Lab)]

I was referring more to situations, of which I know the noble Lord is aware, where there is a need for intervention. I think I used the word “overruling”, and I used some examples where there was a risk to life. So it is about application in that regard. I will look at that question in greater detail when I reflect on this area of debate and, if there is more that I can add to assist the noble Lord, I will be pleased to do so.

Amendment 147 is in the name of the noble Lord, Lord Meston, supported by the noble Baroness, Lady Berridge, and spoken to by the noble and learned Baroness, Lady Butler-Sloss, and the noble Baroness, Lady Bennett. It would create a statutory test of competency for children in respect of decisions under the Mental Health Act. Under that test, competence for under-16s would be defined by reference to the functional test of capacity established in the Mental Capacity Act but without the diagnostic test, and by having due regard to the UN Convention on the Rights of the Child.

The courts have already made clear that the approach of the functional test is not suitable for children. We do not think that the functional test is appropriate or compatible with the UN Convention on the Rights of the Child, which the amendment itself makes reference to. The amendment, as drafted, is therefore not considered to be in line with established case law.

The noble Baroness, Lady Berridge, asked about the justification for not including a test in the Bill. As I have mentioned, Gillick is established in case law, not statute, and the code explains how the Gillick decision is to be applied. But this does not mean that the House of Lords decision is not mandatory. There is a duty to follow case law. It is not discretionary, as I know noble Lords are aware.