Medical Training (Prioritisation) Bill

Lord Stevens of Birmingham Excerpts

Committee stage
Thursday 12th February 2026 Lords Chamber

[Lord Mohammed of Tinsley (LD)]

My Lords, I speak to the amendments in this group in my name—Amendments 5 and 10—and to Amendments 9, 11, 24 and 25 in the name of the noble Lord, Lord Stevens of Birmingham, which I have also signed.

I follow up the point that the noble Earl, Lord Howe, talked about in terms of the fairness for those people who went into the application process last summer. They started this process with the expectation of getting a confirmation any time now and being able to prepare. That is why my Amendment 5 proposes to postpone the implementation of this speciality training prioritisation for this year’s intake, so that those people who are applying for 2027 know that we are changing the rules, rather than telling those people who applied last summer that we have changed the rules. Let me be clear from the outset: this amendment does not seek to undermine the principle of the objectives of this Bill on medical training; rather, it seeks to ensure that these objectives are implemented fairly, coherently and without unintended harm to the very trainees upon whom our healthcare system depends.

The central issue for us here has always been timing. As the Bill currently stands, these changes would be introduced during an active application cycle. This raises serious concerns about procedural fairness and legitimate expectations. Applicants have made life-altering decisions—academic, financial and personal—based on a set of rules that existed last summer when they applied. To change these rules mid-cycle, in my opinion, is not merely inconvenient but fundamentally unjust. Like many others, I have been contacted by affected medical students who have articulated their concerns around the criteria. They noted that they had complied fully with all the requirements enforced at the time of application, only to find themselves potentially excluded by the change that has now been imposed. Without transitional protections, the Bill would disadvantage applicants who acted in good faith, followed the guidance provided and had every reasonable expectation that the rules would not be rewritten half way through the process. This is not about isolated grievance; it reflects a systematic risk inherent in rushed implementation.

Medicine is a profession that demands long-term planning, with years of study, examination, placement and significant personal sacrifice. When Parliament alters the conditions of progression without adequate notice or transition, it destabilises that planning and erodes trust in the system. My amendment therefore offers a modest but proportionate and sensible solution: a one-year delay that would allow for clarity in communications and proper preparation. It would give institutions time to adjust their process, regulators time to issue clear guidance and applicants time to make informed decisions so that people who will be applying this summer know what the criteria are. Crucially it would also align with the principles of this House, which has long upheld fairness, legal certainty and an avoidance of disadvantage. We should be especially mindful of these principles when legislating in areas that directly affect access to professional training and career progression.

There is also the practical consideration. Disruption of the current application cycle risks creating gaps, appeals and bottlenecks that could ultimately harm workforce planning in the NHS. At a time when staffing pressures are already acute, we should really be wary of reforms that may have unintended consequences and might deter capable candidates. My amendment would not delay the reforms indefinitely, but simply ensure that reforms are done properly. By supporting this amendment, we would send a clear message that, while we are committed to improving medical training pathways, we are equally committed to treating applicants fairly and honouring the rules under which they apply.

We have heard about the immigration status mentioned earlier and the criteria on which that is based. With my Amendment 10, I would like to raise with the Minister the alternative option, given that the Government are also seeking to change the rules around indefinite leave to remain. My understanding is that there is a better option. The NHS has its own recruitment platform, the Oriel system, which is able to demonstrate professional commitment to the NHS. In doing so, it shifts the focus from legal residence status to actual service, contributions and engagement with our health system.

The NHS does not run, as we heard earlier, on immigration categories. It runs on people who turn up to shifts, who trained within its system, who understand its pressures and who have committed themselves to caring for patients day in, day out. The Oriel registration is not just a symbolic tactic; it is a gateway through which NHS recruitment, training and workforce planning operates. It is a clear, objective indicator that an individual is already participating in or seeking to participate in the NHS.

Similarly, the concept of professional commitment to the NHS allows for a broader and fairer assessment of contributions. It recognises work undertaken in the NHS trust, clinical placements, foundation training, research, teaching and other forms of service that directly benefit patients and institutions. This approach reflects reality far more accurately than a single immigration milestone, which may have little bearing on an individual’s clinical engagement or future commitments or intentions.

There is also a serious risk of equality issues at stake. Many doctors who have trained in the UK, worked in NHS hospitals, paid taxes and served our communities for years do not yet hold indefinite leave to remain, due to the structures and lengths of immigration pathways. To divert these such individuals despite their proven service risks sending a deeply damaging message that contribution is secondary to paperwork. At a time when the NHS remains heavily reliant on international medical students, we should be careful not to erect barriers that discourage retention or undermine morale. These clinicians are not temporary stopgaps; they are integral members of our workforce. Many intend to build long-term careers here and many already have.

From a practical standpoint, this amendment also improves administrative clarity. Assessing our registration and documenting NHS experience is straightforward, verifiable and directly relevant to workforce needs. By contrast, tying prioritisation to immigration status risks complexity, inconsistencies and unintended exclusion. If the aim of the Bill is to strengthen medical training and to support the NHS workforce, our criteria must align with that goal. This amendment ensures that prioritisation is based on what truly matters: demonstrated commitment to the NHS and the work that it exists to do. Therefore, I urge noble Lords to support both my amendments.

[Lord Stevens of Birmingham (CB)]

My Lords, I repeat my declarations of interest from Second Reading as chair of King’s College London and chair of Cancer Research UK, and as an honorary fellow of the Royal College of Physicians and the Royal College of General Practitioners. I am going to speak to my Amendments 9, 11, 24 and 25. I am most grateful to my co-signatories: the noble Earl, Lord Howe, and the noble Lords, Lord Mohammed of Tinsley and Lord Patel.

The Government, in my opinion rightly, want to prioritise for specialty training doctors who, among other things, have significant prior experience working in the NHS. They propose in the Bill that that would be an explicit criterion to be taken into account from 2027. So the principle is clear. The practice for 2026, however, is said in the impact assessment to be such that they cannot use that criterion for the current cycle. So, instead, a series of proxies are proposed which, in the words of the impact assessment, would

“capture applicants who we believe are most likely to have NHS experience”.

This set of amendments, which should be an easy pill for the Government to swallow, would simply give them the ability to apply in 2026 the same criterion relative to work experience in the NHS that they propose from 2027 onwards. I recognise that there may still be some discussions, as we just heard from the noble Lord, Lord Mohammed of Tinsley, about the executability of that criterion, using the Oriel system or other mechanisms. These amendments would not require the Government to bring forward their 2027 approach but simply permit them to do so if, in the weeks between now and 5 March, for example, if that is the deadline for when Royal Assent is required, it becomes clear to them that the modest enabling work on the computer software, estimated at £100,000, can be put in place if that were needed.

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[Baroness Merron (Lab)]

I cannot give an exact proportion, as the noble Lord is aware, but I have noticed that the proportion has changed as the Bill has progressed. As we have approached Committee, I have certainly seen more email traffic urging a non-amended Bill rather than an amended Bill. I would imagine that that is reflected in other emails. The noble Lord is indicating that it is not. I can see differing responses, but that has certainly been my impression.

The application of prioritisation to the 2026 intake is necessary and justified. If, as I referred to earlier, we waited until 2027, competition ratios are projected to rise even further, meaning that more UK graduates would be unable to progress their careers on time, with a greater risk to the long-term sustainability of the workforce. For these reasons, another year’s delay is not an option, and we cannot accept the noble Lord’s amendment.

Amendment 10, also tabled by the noble Lord, Lord Mohammed, also seeks to change categories of people who would be prioritised for specialty training places, starting in 2026, by virtue of having significant NHS experience or by reference to their immigration status. We cannot accept this amendment on the basis that the effect would be to prioritise every individual who applied for specialty training places in 2026 because all applicants are, by necessity, already registered on Oriel. This amendment would in practice nullify prioritisation for 2026 and render the legislation ineffective. It would not address the severe and growing bottlenecks in specialty training that the Bill aims and is designed to tackle.

The proposal to prioritise those who have demonstrated a professional commitment to the NHS also presents workability problems as there is no clear or objective definition of what such a commitment looks like, nor any reliable way to assess it for tens of thousands of applicants at this stage. Attempting to do so would be unmanageable in a practical sense and would introduce inconsistency, delay and uncertainty for applicants.

[Lord Stevens of Birmingham (CB)]

One objective proposition that has been suggested is two years of NHS experience, which, it is said, would be readily trackable on Oriel. Can the Minister confirm whether that would indeed be possible?

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[Lord Stevens of Birmingham (CB)]

My Lords, I speak in support of the thrust of the amendments in this group. I start by acknowledging the concern that I think is animating the Government on this point, which is that they do not want to see a thin end of a wedge that opens up substantially with a lot of newly created international programmes that then end up further displacing UK-trained graduates and undermining the ability to effectively plan the medical workforce of the future.

Fortunately, however, none of these amendments actually constitutes the thin end of the wedge—there is no wedge. As we have just heard, these amendments grandfather the current, very modest arrangements at QMUL Malta and Newcastle University, which are so numerically small, with a couple of hundred students relative to 12,800 for the other training programmes. So those are not the programmes that have caused the problem that the Bill is seeking to address, nor should they therefore be collateral damage as the Bill progresses.

As discussed at Second Reading, particularly in respect of Malta we have a long-standing relationship, and we have a series of diplomatic and other ties of bilateral agreement that the British Government and the Maltese within the last 12 months have renewed, which are of continuing and considerable significance to us, including on defence, security and other aspects. So the Government would be well advised not to throw the baby out with the bathwater and to take seriously the concerns that these amendments represent.

[Lord Mohammed of Tinsley (LD)]

I shall speak to the Amendments 15, 16 and 19 to add my support to the amendments on the issue of Malta from the noble Baroness, Lady Gerada, as well as Amendment 17 from the noble Lord, Lord Forbes, and Amendment 20 from the noble Earl, Lord Howe.

Given that we have had a substantial discussion on Malta, particularly from the noble Baroness, Lady Gerada, and the noble Lord, Lord Clement-Jones, I shall speak more towards Newcastle, forging the northern alliance that we may have—and more importantly because my mentor, the noble Lord, Lord Shipley, who cannot be here, made a particular point of visiting my office to say, “You are going to be speaking on Newcastle on Thursday, aren’t you?” So here we go.

The amendment from the noble Lord, Lord Forbes, would ensure that graduates from overseas campuses, and United Kingdom medical schools in particular, are treated fairly and consistently. I think that the amendment is precise and proportionate. It applies three conditions: first, that the primary medical qualification is awarded by a United Kingdom medical school—in this case Newcastle, but there will be others; and, secondly, that the qualification is obtained through study at an overseas campus that existed at the point of this Act being passed. The noble Baroness talked about potential creep when we discussed this last week in terms of other institutions being able to take advantage and open that back door. With this very timely amendment from the noble Lord, Lord Forbes, it is very clear that—

[Lord Stevens of Birmingham (CB)]

Is it the noble Lord’s understanding that there would be the opportunity for creep as is currently set out in the Bill? For example, if Queen Mary University of London wished to establish a medical school in Liechtenstein, which currently lacks one, it would be able to do so with an unlimited number of places. All those new students would then be passported into the NHS.

[Lord Mohammed of Tinsley (LD)]

The noble Lord, Lord Stevens, has given people ideas. Possibly, this could happen, yes.

Thirdly, both courses and study for the convocation are approved by the GMC as being equivalent to the UK medical qualification. This is not about lowering standards or creating a new route through the back door. On the contrary, this is about recognising the standards that already exist and are regulated by the GMC. The GMC is determined that these courses are equivalent in content assessment and outcome. It is difficult to justify why we should exclude them, given the numbers that we heard about earlier.

Universities such as Newcastle—and there may be others as well—rely heavily on this partnership. These programmes have not just happened overnight. They have existed for some time. They are run by UK institutions, aligned with UK curricula and assessed identically to UK standards and subjects. Graduates receive UK-awarded degrees, not foreign substitutes. Such programmes contribute to the NHS. Only yesterday, we heard from Newcastle University that they have had up to 150 students on their Malaysian campus. As we heard earlier, some of those students have come back to the United Kingdom and, in particular, have served for many years as GPs when we have had an acute shortage. We need to take heed of that contribution and also the long-standing relationships that exist both with Newcastle and Queen Mary.

We are only asking for a very small change. We are not asking for tens of thousands of students to come here. We are asking for a small number through long-established partnerships that have existed and stood the test of time. We are asking the Minister for some flexibility. This is being heard from all sides of your Lordships’ House. We are about to go on a holiday. I hope that the Minister will take this time to reflect on our debate and come back on Report with government amendments that we can all support. I look forward to the debate that we are going to have in less than a fortnight’s time.

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[Lord Stevens of Birmingham (CB)]

I want to come in on the point about whether or not the UK Government would lack the ability to control the expansion of international places in the grandfathered campuses. Is it not the case that, in fact, the UK Government do have such a tool at their disposal, through the Office for Students? The OfS has to agree the number of undergraduate medical places that a university can operate here in the UK and can cap those, and could therefore introduce an off-setting mechanism so that any additional place created outside the UK would see a reduction in the UK authorisation. That would be incentive enough, I suspect, to ensure that universities did not behave in the way that the Minister is concerned about.

[Baroness Merron (Lab)]

The noble Lord kindly raised this with me before, and I did test it out. I am grateful that he has given thought to this, because it is an important point. However, I am advised that, unfortunately, the solution that he has come up with would not deal with all the concerns we have and would still give us difficulty. The noble Lord talked about the thin end of the wedge, and I fear that we are still in the same place. I am happy to write to the noble Lord, and to make that letter available, to explain further detail. I am grateful that he has given consideration to a solution for what is undoubtedly an issue.

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[Lord Kamall (Con)]

My Lords, in speaking for the first time in Committee, I refer to my interests as a professor of politics and international relations at St Mary’s University, Twickenham, where I teach an MBA module on healthcare policy and strategy, and where I also co-operate with the school of medicine, which will start accepting students later this year. I also work as an honorary fellow at the Vinson Centre for the Public Understanding of Economics and Entrepreneurship at the University of Buckingham, which also has a medical school but with which I have no direct connection.

I tabled Amendment 22 to facilitate a wider debate on the level of provision of medical training places and its impact on the outcomes for doctors and, by extension, patients, as well as the need for regular review. We all agree that the NHS and other health providers need highly qualified staff if they are to deliver the quality care that people expect of them, but that means that policymakers should seek to establish an education system that encourages young people to see the benefits of medicine as a career path, supports those going through medical training every step of the way and removes barriers to those who want to be doctors. As my noble friend Lord Howe said earlier, currently, too many young doctors reach the point at which they need to secure a medical specialty training place but find themselves disappointed, either because they are unable to access a training place or because the training place they are able to secure does not meet their needs.

A 2023 study by Tomas Ferreira on the career intentions of medical students found that many medical students finishing their foundation programme do not intend to take up medical specialty training places. The report says

“we report an increase in intention to not take up specialty posts immediately after the Foundation Programme, with an increase from 6.75% … of first-year students to 35.98% … of final year students. A contributing factor to this scenario could be a significant increase in competition ratios for specialty training posts, partly due to increasing medical student places and no corresponding increase in the number of training posts available”.

The lack of specialty training places to retain those medical students within the NHS is a challenge that the Government and we all face—something, I concede, we realised perhaps too late when we were in government. If the issue is not tackled, we will continue to see talented young doctors who might otherwise prefer to stay in the UK and work within the NHS, and maybe other health providers, leaving the UK to complete their training elsewhere.

The Government have announced their offer to the BMA to expand specialty training posts by 4,000, with 1,000 of them brought forward this year. That expansion in training places is welcome and necessary. I ask the Minister to confirm whether there will be any delay in their delivery and whether they will be delivered this year.

In May last year, I tabled a series of Written Questions on resident doctor medical training places, and the responses showed that very small numbers of training places are available in some regions. For example, in 2024, just one medical oncology specialist training stage 3 post was offered in the whole of the north-east region. The figure for the Wessex region was two places. For the earlier specialist training stage 1 posts in gynaecology, the Wessex region had just 11 places in 2024, while the whole of the south-west region had just 16 of those places. Can the Minister say whether those numbers are meeting the needs of those regions and whether there is a gap? What are the key factors that restrict the number of training places that can be offered in those regions?

The overall number of training places is probably the most important challenge young doctors face, but there are other considerations that affect talent retention. The geographical distribution of training places is also something that we all know needs attention. Last month, the Government announced that they will introduce new training places targeted at trusts with the biggest workforce gaps, prioritising rural and coastal areas, where patients currently struggle the most. We welcome that. That is good news. But, in designing this policy, I ask the Minister what assessment the Government have made of the number of medical students who actually want to train in these rural areas and whether that is a factor in some UK medical graduates choosing to go abroad or is irrelevant.

In response to concerns from the BMA about the challenge of doctors having to cover the upfront cost of their training, the Government have offered cost-related measures in their offer to the BMA, including reimbursement of exam fees. I ask the Minister for a little transparency and to give the Committee more detail on how reimbursement would work if the BMA were to accept that offer.

I hope that the Minister is able to answer these questions, either today or later in writing. I assure her that we look forward to working constructively with the Government as they face up to these workforce challenges. I beg to move.

[Lord Stevens of Birmingham (CB)]

My Lords, to help the Committee to assess the need for this further report that the noble Lord, Lord Kamall, just set out, it would be helpful if we could hear from the Minister when the Government will produce their replacement long-term workforce plan for the 2023 edition, which itself was deemed to be long term but ended up having a half-life of less than two years. How imminent is that and will it deal with the sorts of points that the noble Lord, Lord Kamall, rightly brings to our attention? When will we see the follow-on to the excellent Medical Training Review: Phase 1 Diagnostic Report, authored by the Chief Medical Officer and the previous National Medical Director of NHS England, published in October, which sets out these issues extremely well? The clue is in the title: it is the diagnosis. But when do we get the prescription? When does the treatment begin?

In a sense, the problem that we are dealing with through the Bill—again, as the noble Lord, Lord Kamall, just set out for us—owes its antecedents to the disconnect between the provision of NHS services and the ability to make smart, long-term workforce decisions. Unfortunately, for the period 2012 to 2022, those decisions on medical training were outwith the NHS and in effect were being controlled by the Treasury, which was constantly saying no to Health Ministers who were at the time trying to bring forward constructive solutions. Indeed, it was only when a former Secretary of State for Health became Chancellor that the situation was unblocked and we got the medical school expansion. Perhaps that is an inspiring example for the current Health Secretary—I do not know; perhaps he aspires higher. The fact is that we need that whole-government engagement on these kinds of questions to bring coherence and deal with these problems at root. Therefore, in responding to the noble Lord, Lord Kamall, any light that the Minister can shed on when precisely we will have line of sight to these sorts of questions would be, I think, of great benefit to the Committee.

[Lord Clement-Jones (LD)]

My Lords, I support Amendment 22, standing in the name of the noble Lord, Lord Kamall. He absolutely made the case but, having heard what the Minister had to say on the previous group, I have a terrible certainty about what her response will be.

I assure the Minister that many of us want to find solutions, in the way that the noble Lord, Lord Stevens, mentions. The principles of the Bill are supported across the Committee; it is some of the detail that is in contention. We must be honest that the Bill deals with the symptom—competition ratios—not the cure, which is the bottleneck of insufficient specialty training places. I go back to the phrase that the noble Lord, Lord Stevens, used at Second Reading. We are simply reshuffling the queue.

This amendment places a necessary duty on the Secretary of State to review the adequacy of training places. We have received warnings from doctors in shortage specialties such as psychiatry and general practice, who fear that the Bill will drive away the international talent that we rely on. We need to know whether this legislation will succeed in retaining UK graduates or whether it will inadvertently exacerbate shortages by signalling to the global medical community that the NHS is closed for business. We cannot manage what we do not measure.

Medical Training (Prioritisation) Bill

Lord Stevens of Birmingham Excerpts

2nd reading & Committee stage
Wednesday 4th February 2026 Lords Chamber

[Lord Stevens of Birmingham (CB)]

My Lords, I declare an interest as an honorary fellow of the Royal College of Physicians and the Royal College of General Practitioners, and as chair of the council of King’s College London, which is Europe’s largest educator of health professionals. I too congratulate the noble Lord, Lord Roe, on his excellent maiden speech. Given the deteriorating physical fabric of the Palace of Westminster, it is reassuring to know that we have a firefighter in our midst.

I start by endorsing the thrust of the policy set out in the Bill. It clearly makes sense for the NHS and for British taxpayers to properly connect undergraduate medical education with access to specialist training, and then the flow-through of doctors able to contribute over the balance of their careers to the work of the NHS. All that makes total sense. Nevertheless, I echo three of the concerns we have heard already in the brilliant contributions to this debate.

The first is about the difficulties and concerns around the transition year, 2026, that the Bill proposes. For 2027 and beyond, rightly, there is the suggestion in the Bill that applications will be prioritised from doctors with NHS experience, who have made a contribution to the NHS. But because of not being able to get the computer system right, that is excluded for the 2026 transitional period.

As we heard from, I think, the noble Lord, Lord Clement-Jones, there is a range of views that suggest that that is not a correct assessment. I think the impact assessment says it is £100,000 to sort out the Oriel computer system—against a £4.3 billion taxpayer expenditure in this area. This is an area where the Minister and the Minister in the Commons, Karin Smyth, might want to give officialdom a little tap and just double-check that what they are being told is right, not least because there is a degree of oddity about this in that the Government declared their intention to introduce this new prioritisation for UK graduates seven months ago. It was in the 10-year NHS plan published on 3 July. It is not completely clear why there has been a seven-month lapse before we get this emergency Bill that has to be passed within four weeks.

There is the transitional 2026 concern and then, relatedly, there is the question of whether, by just changing the prioritisation, the Government actually have a game plan to deal with the more fundamental, underlying problem of the bottlenecks. This piece of legislation by itself does not widen the bottlenecks, it just changes who will occupy them. As the noble Earl, Lord Howe, I think, asked, it would be very useful to know, of the 1,000 additional specialty training places over three years promised in the 10-year plan, or the 4,000 put on the table in December as part of the Government’s negotiation with the BMA—of which 1,000 extra were to be in place for the coming year—what is their current assumption about the expansion in specialty training that will go alongside this reprioritisation for 2026 and 2027?

Today, we have seen the publication of the cancer plan, which, quite rightly, says that the Government

“will work with the Royal Colleges to encourage resident doctors and internal medicine trainees to specialise in clinical and medical oncology”—

where there are significant shortages—and will prioritise

“training places in trusts … where vacancy rates are higher and performance is lower”.

Can the Minister tell us whether the Government will give effect to that commitment in the cancer plan with the 2026 and 2027 increases in specialty training places, which are clearly required?

To circle back to a point that the Minister made—and, indeed, the Health and Social Care Secretary made at Second Reading in the Commons on 27 January—the Government’s estimate appears to be that even with this tighter, or reshaped, prioritisation, there will still be a ratio of two applicants to every place for specialty training. Just stand back a moment—that means we will be turning away half the doctors who would be able to fill those places. Are the Government sure that they are going pedal to the metal on the expansion in specialty training to reduce that oversubscription rate?

How does that connect with the upcoming rebadged, or refreshed, long-term workforce plan, given that the undergraduate doctors who start their training this year will be, in practice, coming out to deliver clinical care as consultants from 2040 and training their successors up to 2070? We really do need a long-term plan here, rather than the constant chopping and changing that, sadly, we have seen.

Finally, I completely endorse the comments about Malta. Three collective institutions have been awarded the George Cross—Malta and the NHS are two of them. We should sustain those relationships. The idea that we have less in common with the Maltese than with the good people of Liechtenstein—I have just had a quick look and Liechtenstein has one 35-bed hospital and a per capita GDP more than three times that of the UK—misses the point. We have to see the wood for the trees; the Department of Health and Social Care needs to raise its gaze and value these historic relationships that are so important for us.

Terminally Ill Adults (End of Life) Bill

Lord Stevens of Birmingham Excerpts

Committee stage
Friday 30th January 2026 Lords Chamber

I hope the sponsors of this amendment might consider a redrafting that takes account of these fundamental differences, retaining access to helpful diagnostic tools while excluding a general-purpose superintelligent AI, still to be developed, from a decision-making process that properly resides in human agency.

[Lord Stevens of Birmingham (CB)]

Essentially, I agree with the right reverend Prelate the Bishop of Hereford. I could almost leave it there, but I will briefly say, in the spirit of the amendments, that the tablers are right to raise general concerns about the possibility of abuse through bias—as we heard from the noble Baroness, Lady O’Loan—and hallucination. After all, we have had the first high-profile resignation of a public sector leader in the form of the chief constable of the West Midlands praying in aid the fabrication of a non-existent football match as the reason why Parliament was misled.

In addition to bias and hallucination, there is the risk of what is called scheming. The results from some of the LLMs—published, for example, in the journal Nature in October—show some pretty disturbing examples. In the article, headed “AI Models that Lie, Cheat, and Plot Murder”, there are examples where models have attempted to write self-propagating worms, fabricate legal documentation and leave hidden notes to future instances of themselves. The punchline, essentially, is that, in regard to some of these technologies,

“the world is in a lucky period in which models are smart enough to scheme but not smart enough to escape monitoring”.

That is scary because, in five years’ time, that may no longer be true. So there are good reasons for generalised concerns about AI and wanting to circumscribe the role it might play in this legislation.

However, for the reasons that others have mentioned— I suspect the noble Baroness, Lady Coffey, herself would accept this—this probing amendment is written too broadly. It says:

“Artificial intelligence must not be used to carry out any functions in any section or schedule of this Act”.


Given that, for example, under Clauses 5(5) and 12(2), a doctor has to discuss with a person their diagnosis, their prognosis, any treatments available, the likely effects of them, and palliative, hospice and other care, it is highly likely that those will be informed by machine learning. It will interpret, for example, CT scans or MRIs, and AI tools will personalise and optimise therapies, potentially with predictive AI for better prognosis. So, were this to come back on Report, there would be a good case for ensuring greater precision in the firepower that is aimed at this particular concern.

However, all that should not in any way excuse or divert us from an equivalent worry: we must not kid ourselves that the gold standard is human expert judgment on many of the questions posed by the Bill. As we discussed, Clause 2(1)(b) requires an assessment of whether somebody with a terminal illness will live longer than six months. Unfortunately, as we have heard, that turns out to be a clinically irrelevant threshold that is very hard for expert judgment to get right.

I have just pulled the data from a large study looking at 98,000 people across London over the last decade and at prognostic accuracy, and the answer was that clinicians were able to be accurate about whether somebody was going to live for two weeks with about 74% accuracy, and they were able to be accurate about whether somebody was going to live more than a year with 83% accuracy, but, in terms of being able to predict whether somebody is going to survive for weeks or months, accuracy was only 32%. So, whatever our concerns about AI, human expert judgment, which underpins the Bill, is itself highly fallible.

[Lord Markham (Con)]

To follow on from that, as my noble friend said right at the beginning, the amendment was put down in such a blunt fashion absolutely to stimulate this sort of debate. What has been really useful in this debate is finding that there is a broad degree of consensus that AI can be valuable as an input to decision-making, but it should not be used as the output: as the final decision-maker. As mentioned, AI can detect the progression of cancers and can probably do better prognosis or improve, especially over the time that we are looking at here, so that you can get better assessments of how long someone is likely to live.

On the AI in the chat box, there are very many instances where it could be very useful in terms of detecting coercion if it is talking to someone over quite a long period of time. Therefore, in all of this we see that, with inputs to the decision-making process, AI has a valuable part to play, but I think we would also absolutely agree that the final decision-maker in terms of an output clearly has to be a human; obviously they will be armed with the inputs from AI, but the human will make the final decision. I think that is what the Bill does, if I am correct, in that it is very clear that the decision-makers, the panels, the doctors and everything are those people, but at the same time—although I guess the Bill is silent on this—obviously it enables AI as an input.

I hope this debate is useful in that it shows a degree of consensus and that in this instance we probably have the right balance, but, again, I would be interested to hear from the Bill sponsor in his response whether that is the case.

Tobacco and Vapes Bill

Lord Stevens of Birmingham Excerpts

Committee stage
Wednesday 26th November 2025 Grand Committee

[Baroness Bennett of Manor Castle (GP)]

My Lords, I thank the noble Earl, Lord Howe, for introducing this group. I will speak in specific terms against Amendment 188 and very strongly against Amendment 200A.

Starting with Amendment 188, I declare my position as a member of the All-Party Parliamentary Group on Customer Service. I note the terrible figures from the Institute of Customer Service earlier this year—these are from people who work in all areas of public-facing customer service—which showed that 43% of those surveyed had faced some incident of customer hostility in the previous year. That figure was up nearly 20%. Some 21% of the people surveyed had also faced physical threats while they were doing customer-facing roles.

As the noble Earl said, we have a real problem with shoplifting, but we also have a problem across the board. I do not think the best way to approach this is to look specifically at retailers of tobacco, vaping and nicotine products. There is a need for government action, and I have been working with the Institute for Customer Service more broadly, as I have in the past on other legislation, to tackle this. It does not make a lot of sense to regard this as a discrete problem; it needs a much broader angle of attack.

I am very strongly against Amendment 200A, which would establish a government grant scheme to subsidise the cost of age-verification technology to reduce the financial burden on smaller retailers. I absolutely agree that the burden should not fall on smaller retailers. However, I point out that—this is based on work earlier this year by the Social Market Foundation—the big four tobacco companies make £900 million in profits annually and that their average profit margin, looking at the cost of producing and distributing tobacco products versus the price they charge to whole- salers, is 50%. There is no other product that has anything like that kind of return.

Due to being involved here, I have not had a chance to look closely at what happened in the Budget today but, so far as I have been able to discover, a fairly standard increase in tobacco duty is coming in at 6 pm today. However, the Chancellor has not, it seems, followed the recommendation of the Social Market Foundation to put a levy on tobacco products on some of those windfall profits. At the time, that was suggested for health measures, but it could indeed go into such a measure as this. It is very clear that the merchants of death should be paying for the costs associated with their products much more broadly than this. But, certainly in the context of this amendment, they should meet any burden of compliance so that it does not fall on the smaller retailers.

[Lord Stevens of Birmingham (CB)]

My Lords, I hesitate to interject at this late stage of Committee, but I just respond to the noble Baroness, Lady Fox, who had concerns that many of the organisations giving evidence previously on the retail question were from health-related charities, and I declare my own non-pecuniary interest as chairman of Cancer Research UK.

I just inject a note of caution about relying too heavily on some of the trade associations for the small retailers that she describes, given that they have some financial vested interests. The organisation that she cited, I noticed on their website, has received a sponsorship support from Japan Tobacco International. Another major retail association declares on its website that it has received funding from Philip Morris, Japan Tobacco, Imperial Tobacco and British American Tobacco. Therefore, notwithstanding the need to consult retailers directly, I think that some of these trade associations may have a conflict of interest.

[Baroness Walmsley (LD)]

My Lords, I agree with the noble Earl, Lord Howe, about how important it is that retailers of all kinds feel supported as we move into the transition to a smoke-free generation. Those who operate legally and who will obtain a licence to operate under the new rules will want to see the Government doing everything that they can to attack the illicit trade that undermines the profits of law-abiding businesses.

They also need protection from the wave of shoplifting, which the noble Earl, Lord Howe, talked about, which eats into their profits and sometimes puts them in physical danger. It is quite possible that progress towards gradually raising the age below which the retailers may not sell tobacco products could exacerbate this situation unless action is taken. Age verification could be seen as a problem or a solution. However, the need for age verification is already quite common and it falls upon the consumer, not the retailer. I have to verify my own age when I buy a senior railcard to use on the train, although my grey hair means that I am not challenged when I want to buy a bottle of wine. However, the fact remains that, when I have alcohol in my basket at the checkout, a member of staff is entitled to verify that I am over 18—in fact, they take one look, and they click on the terminal. They do not ask for my birth certificate, but of course they might if I looked under 18, which I do not.

However, the situation will soon change for young people only a year apart in age. Having said that, young people are already quite used to having to verify that they are over 18 when buying a drink or a packet of cigarettes or vapes. What do they do now? They use a digital age-verification tool already, and some bars issue their own card once they have verified the age of their regular customers. It therefore would not be unreasonable, and would be helpful to the retailers, if a range of age-verification mechanisms could be available to customers who would then have to show one of them in order to protect the retailers from inadvertently committing an offence. They have to show that they are over 18 now, so why not that they are 19 a year after Royal Assent or 20 the year after that?

It may be a very good idea for the Government to carry out more research on this and publish a strategy, as the noble Earl, Lord Howe, has proposed in Amendment 188. But the public are not the only ones who need guidance and information about the law well before it comes into operation; how much more important is it for retailers? We have already debated my noble friend Lady Northover’s amendment about the need for a communications strategy, so I am not sure how much Amendment 191 would add to that, but it is a useful probe.

Like the noble Baroness, Lady Bennett of Manor Castle, I do not support Amendment 200A from the noble Lord, Lord Howard of Rising. I do not see why taxpayers should foot the bill for creating age-verification mechanisms. I suspect that individual customers will obtain their own digital age-verification mechanism and that inventive companies will produce them and make them readily available. Of course, the vape manufacturers may also produce age-gated products, so perhaps it should be the tobacco industry that foots the bill because of its very large profit margins. I look forward to hearing the Minister’s views on this issue.

Tobacco and Vapes Bill

Lord Stevens of Birmingham Excerpts

2nd reading
Wednesday 23rd April 2025 Lords Chamber

[Lord Stevens of Birmingham (CB)]

My Lords, I declare my interest as chair of Cancer Research UK, and it will not be surprising to learn that CRUK and I strongly support the Bill.

Fundamentally, the tobacco industry has a structural problem, which is that it kills 80,000 of its most loyal customers every year and therefore has to restock annually to keep its coffers full—those people being now, sadly, in their coffins. The point of the Bill is fundamentally to do something about that. As the Minister said, it was very gratifying to see the wide support across all parties in the House of Commons, and I hope we will see that repeated here. However, I suspect there will be some objections during the passage of the Bill—some legitimate and well-intentioned criticisms, but potentially some that bear a strange family resemblance to the arguments that the tobacco industry and its proxies also advance.

One of those objections is that the Bill is not actually needed because smoking is on its way out anyway. I am sure that we can appreciate the irony of the argument that the industry advances that the very measures that it has previously so vigorously opposed on the grounds that they would be ineffective are now allegedly so supremely effective that further regulation is not required. Leaving aside the irony, the fact is simply that 6 million people are still smoking. The rate of progress is nowhere near sufficient to get us to the previous and current Governments’ target of being de facto smoke-free by 2030. In the poorest parts of the country, that is not going to be until 2050, and, since the general election, it is estimated that 100,000 more young people have taken up smoking.

Therefore, it is not true that further action is not needed; nor is it true that we should not take action in the absence of “real-world evidence”, because, of course, that is an entirely circular argument. You will not get real-world evidence until you do it and see the effects. The subtlety of the Bill is that the annual rise by one year in the age of sale will give us that evidence as we see the successive, cumulative effect that these measures bring about.

Another argument that we have heard is, “Why not just raise the age of legal sale to 25?” If you do the maths, for the next nine years, between now and 2034, we will be on that journey anyway. That will give us ample time to see whether the measures in this Bill are working as intended.

Then there are the crocodile tears: “This will be bad for the Treasury because of all the tobacco excise duties which are forgone”. If that is your argument, have the courage of your convictions and go into bat for the Government promoting smoking as a way of boosting the coffers of the Treasury. In any event, that is to ignore the wider economic arguments which the noble Baroness set out.

Then there is the zombie argument, that the black market will develop and prosper with each incremental regulatory step we take. As a matter of fact, rather than a debating point, the number of smuggled cigarettes has fallen by over 85% since regulations of this nature to clamp down were introduced 25 years ago. The most recent data from HMRC shows that the forgone duty from smuggled or black market cigarettes as a proportion of the theoretically available total has fallen from about 17% in 2005 to about 7% now. The question of enforcement is independent from the question of regulation. We can do both.

Finally, we get to: “Can we at least leave vapes out?” Here, again as the noble Earl, Lord Howe, and the Minister have set out, there is a balance to be struck. The current scientific consensus is that smokers switching to vaping will reduce the threats to their health, but equally that there is no health benefit from taking up nicotine addiction if you have not previously been a smoker. That is why it is right that there is flexibility in the Bill. I say to anybody who doubts what is going on out there that as I came into Parliament this afternoon, I stopped at a newsagent. I know that visual aids are not allowed, but there were Pokémon cards with cartoons next to vapes with a little cartoon character of a vampire, at kids’ eye height, being sold near this building. The idea that the industry has changed its spots is untrue. There has been no damascene conversion. It is the sword of Damocles that is producing the change. The Bill deserves our support.

Mental Health Bill [HL]

Lord Stevens of Birmingham Excerpts

Report stage
Wednesday 2nd April 2025 Lords Chamber

I conclude by emphasising that legislative backstops and reporting duties are necessary to ensure that the implementation of the Bill is timely and effective. That is underlined particularly by the delays in the implementation of both the Mental Health Units (Use of Force) Act 2018 and the liberty protection safeguards introduced in the Mental Capacity (Amendment) Act 2019, to replace the deprivation of liberty safeguard systems, neither of which have been taken forward. Both are very relevant to patients affected by the Mental Health Act. I beg to move.

[Lord Stevens of Birmingham (CB)]

My Lords, this Bill has been years in gestation, and we have heard, in Committee and on Report, that it is going to be years in implementation. The Government, not unreasonably, have pointed to two principal rate limiters for that: workforce and funding. As we have just heard in the powerful speech from the noble Baroness, Lady Tyler of Enfield, her Amendment 50 is responsive to the staffing constraints and concerns, and my Amendment 59 tackles the funding question. I am grateful for her support and that of the noble Baroness, Lady Bennett of Manor Castle, and the noble Lord, Lord Scriven.

In a nutshell, as the noble Baroness says, this amendment does not seek to tell the Government, or indeed the House of Commons under its privilege, how much to spend on the NHS. All it says is that there should be a floor on the share of that total going to mental health for a time-limited period while the Act is being implemented; in other words, the Government would continue to decide the size of the NHS pie. The Government, of whichever complexion, could decide to grow or shrink it, but the slice of that pie devoted to mental health would be protected for a time-limited period, not only at the local ICB level but nationally.

We had a debate on this in some detail in Committee, so I will not repeat the arguments in favour, but I will update the House on two developments since then. First, in consultation with the Public Bill Office, this Report amendment is more tightly drawn, focusing specifically on the mental health services that are in scope of this Bill and are required for its implementation. Secondly, as the noble Baroness, Lady Tyler, has just noted, since we debated this point in Committee, new evidence has emerged, sadly, as to precisely why this amendment is needed. Previously, Ministers have argued, in good faith, that the Government are committed to protecting the mental health share anyway, whereas last Thursday, the Written Ministerial Statement disclosed that the Government now intend to shrink the share of NHS funding on mental health services in the year ahead.

The Written Ministerial Statement says:

“This is because of significant investment in other areas of healthcare”.


That is not a justification; it is a mathematical tautology. It reveals a preference entirely antithetical to what will be required over the years to get this Bill implemented.

It may be argued that it is a small percentage reduction, even though it is an important negative new precedent that has been set. However, a small percentage reduction on a large pound note number itself constitutes a large pound note number. Mental health services will be missing out on hundreds of millions of pounds more, not only in the year ahead but over the decade that it will take to implement the Bill. If that is not corrected in subsequent years, over £1 billion of funding has, in effect, been removed from mental health services and the implementation of the Bill as a consequence of that decision.

In summary, there are, sadly, real grounds for concern about whether the implementation of this Act will be properly and expeditiously resourced. If the Government want to argue that this amendment is unnecessary, because they are going to do what it says anyway, it is not clear why they would therefore object to its inclusion in the Bill. But if the Government’s argument is that they do not support the amendment because they would like the flexibility to cut mental health funding shares, then, to my mind, that really points to the necessity of the amendment.

[Baroness Bennett of Manor Castle (GP)]

I rise briefly, having attached my name to Amendment 59 in the name of the noble Lord, Lord Stevens, and backed by the noble Baroness, Lady Tyler, and the noble Lord, Lord Scriven. We saw in Committee multiple amendments all trying to address the resource issue. We have focused on this one because it is both an elegant solution, as the noble Lord, Lord Stevens, just outlined, and it is—emanating from the Cross Benches—a moderate solution that can and I think will attract wide support from around the House.

As the noble Lord and the noble Baroness have said, parity of esteem has never been achieved and, on the current figures, is currently going backwards, in the wrong direction. We have to focus on the fact that the waiting lists for community mental health care for adults and young people and children are twice as long as those for physical healthcare. That is the outcome of the inequality of esteem with which mental health is being treated. I note that the Rethink Mental Illness Right Treatment, Right Time report found that most people living with a severe mental illness experienced worsening mental health while waiting for treatment, with 42% requiring urgent care and 26% being hospitalised. We are aiming to shift from hospital care—in-patient care—to community care, but we are actually forcing things in the other direction because people reach such a state of crisis. I have to preface the horror of what I am about to say with a warning. The Right Treatment, Right Time report found that 25% of people whose mental health deteriorated while waiting for treatment attempted suicide, which highlights how the lack of funding for mental health care impacts on that awful statistic.

This is a step to create a framework that heads in the right direction. As noble Lord, Lord Stevens, said, how could you possibly oppose this?

--- Later in debate ---

[Baroness Merron (Lab)]

My Lords, I am grateful for all the contributions and considerations this evening, to which I have listened closely.

I first turn to Amendment 50 in the name of the noble Baroness, Lady Tyler. Workforce is absolutely a critical factor in enabling these reforms and we have committed to recruiting 8,500 more mental health staff over the course of this Parliament. The impact assessment sets out our expectations for the additional workforce that is required to deliver the Bill.

However, there are already various mechanisms in place to monitor and address concerns about the mental health workforce. The amendment would be duplicative and unnecessary. Providers registered with the CQC—both NHS and independent services—are required to deploy enough suitably qualified, competent and experienced staff, as outlined in Regulation 18 of the Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. If CQC finds a breach in Regulation 18, it can take action.

The Mental Health Act Code of Practice also states that local authorities should ensure that there are sufficient approved mental health professionals and independent mental health advocates. All staff in CQC-registered providers must receive the appropriate training that is necessary to enable them to carry out their duties under Regulation 18 of the Health and Social Care Act Regulations 2014.

At a national level, CQC reports on workforce sufficiency as part of its monitoring of the Mental Health Act report. We would argue that this is a much better process than requiring integrated care boards to mark themselves on how well they are fulfilling their duties.

Furthermore, as I said on Monday and wish to reiterate, we are committed to laying an annual report on implementation, which will set out progress made and future plans for implementation. This will include information on the expansion of the workforce, including second opinion appointed doctors, Section 12 doctors and approved clinicians. It will also include details of the key statistics and outcomes under the Mental Health Act, including detention rates, community treatment order rates and other key metrics, such as racial disparities and outcomes for children and young people, all of which noble Lords rightly seek. I hope this annual commitment will be welcomed by your Lordships’ House and that this, combined with the existing workforce monitoring I have referred to, will allow the noble Baroness to withdraw her amendment.

On Amendment 59, I also understand —as does the noble Earl, Lord Howe—the intention of the noble Lord, Lord Stevens, which is to ensure that we invest in delivering these reforms. I want to be clear: as I said in Committee, there are already mechanisms in the NHS Act to prioritise mental health spend to deliver these reforms.

To reiterate the point that I made previously, we believe that this amendment is not the right mechanism to ensure that we do that. I will return to the three main reasons for that, but I want first to refer to the point the noble Lord, Lord Stevens, made when he spoke of “shrinking mental health spend”.

[Lord Stevens of Birmingham (CB)]

It was the shrinking share of mental health spend.

[Baroness Merron (Lab)]

I thank the noble Lord for that correction from a sedentary position. Perhaps I could provide some more clarity, which the noble Earl, Lord Howe, also asked for.

The proportion of spend is almost exactly the same as it was last year, with a difference of just 0.07%. We understand concerns that the share of overall NHS funding for mental health will reduce slightly. However, this does not mean that mental health funding is being cut, and I would not want noble Lords to think that to be the case. To be clear, spending on mental health support will increase relative to 2024-25 and is forecast to amount to £15.6 billion—an increase of £680 million in cash terms, and equivalent to £320 million in real terms.

Perhaps it would be helpful for me to return to the three main reasons for not supporting this amendment. The first is—as the noble Earl, Lord Howe, helpfully referred to—what I would call a point of principle. Primary legislation should not be used to constrain spending in this way. Multiyear budgets for government departments will be set by the established spending review process, which considers spending in the round and in the context of the Government’s policy priorities. Additionally, it is Parliament that is responsible for scrutinising government spending and approving spending set by departments for the current financial year as part of the estimates process.

Secondly, the amendment as drafted applies only to spend under the Mental Health Act. The mental health system, as noble Lords will appreciate, does not structure its accounts based on the legal framework under which a patient is held. A single ward, for example, could contain a mix of patients under the Mental Health Act and informal patients who would not usually be considered to be under the Mental Health Act. Likewise, community services will support a mix of people, some on community treatment orders and others who are not. It would be impractical to require services to split costs based on the ever-changing patient mix within their care.

The third reason for not accepting this amendment, and perhaps the most fundamental point, is that the share of spend on the Mental Health Act could reduce over time, which is not undesirable. I will explain why. The genesis of these reforms is the review initiated by the noble Baroness, Lady May, to address the rising rates of detention. We all want to see more people cared for effectively in the community so that the need for the use of the Act is reduced. This would require more investment in preventive community services, which, I put to noble Lords, is surely the preferable model for supporting severe mental illness. In creating a legal requirement for the share of spend specifically under the Mental Health Act not to decrease, this amendment would actually preclude the shift from detention to prevention that I know we all want to see.

So, while I absolutely understand the intention, and I can commit that we will invest to deliver these reforms, we cannot support this amendment, which, for the reasons I have outlined, we believe is fundamentally flawed. For these reasons, I hope that the noble Baroness will withdraw her amendment and the noble Lord will not press his.

--- Later in debate ---

Moved by

[Lord Stevens of Birmingham]

59: After Clause 30, insert the following new Clause—
“Consultation: bus funding formula(1) Within six months of the day on which this Act is passed, the Secretary of State must publish a report detailing a proposed bus funding formula for consultation.(2) The report published under subsection (1) must include—(a) the Secretary of State’s rationale for proposing that formula,(b) an evidence-based assessment of the distributional effect of that formula between various transport authorities in England, and(c) any alternative funding formulas that the Secretary of State has considered but chosen not to pursue.” Member’s explanatory statement
This amendment requires the Secretary of State to publish a proposed bus funding formula for consultation, including their reasoning, an assessment of its impact on different transport authorities, and details of alternative approaches considered but not adopted.

[Lord Stevens of Birmingham (CB)]

My Lords, I am grateful to the Minister for her response to Amendment 59. I accept that there are some philosophical differences of view that she expressed. However, I do not think it was right to say that the scope of Amendment 59 does not include any community and preventive mental health care, since the Bill itself includes provisions that relate to those types of services. In any event, now is not the time for further relitigating. I wish to test the opinion of the House on Amendment 59.

Mental Health Bill [HL]

Lord Stevens of Birmingham Excerpts

Committee stage
Monday 24th February 2025 Lords Chamber

This amendment sets out a road map. I am not saying exactly that we do not have the power in your Lordships’ House to say how the Government should spend money, but this amendment sets down a principle that says that we have to move in this direction.

[Lord Stevens of Birmingham (CB)]

My Lords, building on many of the important points we have just heard, I will speak to Amendments 163 and 164 in my name. I thank the noble Baronesses, Lady Tyler of Enfield and Lady Neuberger, and the noble Lord, Lord Kamall, for their support for these two modest proposals, which are parsimoniously drafted but nevertheless potentially impactful if adopted.

The first amendment quite simply says that we will do away with “mañana, mañana” when it comes to implementing this Bill, which we have all spent so much time on and which the patients and advocates are so keen to see adopted, by putting a five-year backstop from the date on which the Bill becomes an Act through to commencement. Commencement of all its provisions must happen no later than five years after the Bill receives Royal Assent. The logic for that is that we all believe that, on balance, by the time the Bill has worked its way through Parliament, it ought to be an injection of improvement for mental health services, so why would we want to delay?

Of course, part of the answer is that there are some rate limiters, which are described elsewhere, including in the impact assessment. If we go through the impact assessment and say, “All right, what are the specific things that it suggests won’t be possible or won’t have got going until year 6 after Royal Assent?”, we will find it is a relatively modest number. For those who want to take a look, it is in table 1 of the impact assessment, at page 17. There are some changes to the second opinion doctor, to the CTOs, to the CTPs and so on, but both the pound note impact and the extra staffing at year 6 and beyond are incredibly modest compared with the overall size of mental health spending that we will incur. The incremental costs beyond year 5 are somewhere between £15 million and £25 million, on a budget that runs to billions. I believe that, in the real world, if we strain every sinew, it will be possible to get this thing done within five years.

There is another reason for thinking that it is useful to have a statutory backstop to implementation in the Act itself: the unfortunate tendency that we have seen in various other pieces of legislation that, when push comes to shove, the decision is made just to kick the can down the road a little further. I think it is fair to say that both principal parties have criticised the other for doing so with legislation that has passed. I think we had some measures in the health Act that the noble Lord, Lord Kamall, steered through on obesity and junk food. They never quite saw the light of day, despite Parliament deciding that they would be a good thing. The then Government were criticised for that. Likewise, we put the time in to create the Higher Education (Freedom of Speech) Act. I think the Opposition criticised the Government for delays in implementing it, despite the fact that Parliament had passed it. Of course, the cause célèbre is social care reform, where we have been happily kicking down the track legislation that has seen dither and delay for over two decades. That should not be the fate of this legislation. Therefore, this simple amendment would put in a backstop to save us from ourselves. Parliament is sovereign. If we want to get the job done, there is no reason to think that we cannot make these changes in less than the time it took this country to fight and win World War II. That is the rationale for Amendment 163.

Amendment 164 simply says that, during the intervening period while this Act is being implemented, it would be unreasonable to shrink the size of the slice of the pie going on mental health services, for all the reasons that we have heard throughout Committee. To make sure that there can be no argy-bargy on how the drafting is laid out, we have lifted the wording exactly from the health Act as it currently is on the statute book around the proportion incurred by NHS England and ICBs that, taken together, relates to mental health. It says that it

“must not fall as a share of their expenditure (taken together) on all health services”,

with a little kicker: to stop the Department of Health and Social Care marking its own homework, the National Audit Office will do a review after each year and provide a report that we can all scrutinise.

Here are some reasons why the Government should not object to this. First, it does not tie their hands on the overall sum of funding allocated to the National Health Service. That is a decision for the Executive and negotiated each year; nothing here would constrain the ability of the Government to increase or cut expenditure on the National Health Service. Nor would it constrain the ability of each integrated care board to make a judgment on its own priorities. It simply says that, in the round—taking the 42 ICBs and NHS England together—it would be unreasonable to think that the share of health service spending on mental health will go down at a time when there is an incredible gap between need and treatment, and when we are trying to implement this legislation.

Fortunately, just before Christmas the Secretary of State, Wes Streeting, signalled his support for the mental health investment standard. This is the opportunity to provide legislative cover for that very welcome announcement. It is possible that the current Secretary of State will not be the Secretary of State for the totality of this Parliament—nobody has a crystal ball. Looking out five years beyond Royal Assent, it is also possible that year 5 will be the first year of a new Parliament. So it is entirely reasonable for Parliament to support the Secretary of State’s intent by legislating in the way set out in Amendment 164, not least because there are some concerning signals from around the NHS that, for the first time since the mental health investment standard was introduced, it is possible that the share of funding on mental health will go down, not up, when taken in the round. We have not yet seen the figures, but perhaps the Minister can confirm whether that is correct. In any event, that simply serves to underline the acute importance of this safety net provision to ensure that the financial firepower is there to get this Act done.

[Baroness Hollins (CB)]

My Lords, I apologise for my absence from earlier debates in Committee. I will speak very briefly in support of these amendments. My noble friend said that we need to save ourselves from ourselves. Actually, we need to raise aspirations to change the culture of believing that it cannot be done and thinking that it will cost too much to take a more preventive approach, to care properly for people in the community and to achieve parity for mental health outcomes. These amendments are really important to try to achieve that, so I support them.

--- Later in debate ---

[Baroness Hollins (CB)]

In adding my support to these amendments, I welcome particularly the contribution from the noble Baroness, Lady Ramsey.

This debate has emphasised why the pathway of care, from the community through to any kind of hospital admission and discharge, must be considered as a whole. It is not okay to separate bits off. That is why the amendments are so important: unless we put provision in place to make sure that, when admission is necessary, it is timely and to a place which has the skills to provide the therapeutic care that people require, detention and admission will in fact be longer and costlier. We cannot contemplate making legislation that does not take account of the whole patient pathway.

[Lord Stevens of Birmingham (CB)]

I have been inspired by the previous two contributions. I will briefly pick up a point that the noble Baroness, Lady Tyler, made about Amendment 134 on the availability of community services, particularly psychiatrists. I think the Minister referred to the longer training times for psychiatrists and other mental health professionals as one of the rate-limiting factors that would affect the speed with which the measures in the Bill could be implemented.

I have a request for the Minister. It is quite hard to tease out from the impact assessment what the Government think the incremental requirements for psychiatrists will be, year by year, over the implementation period. In fact, slightly perversely, they use mixed currency: the Minister responded, rightly, to Amendment 163 by saying, I think, that there was a requirement for 400 additional psychiatrists for the second opinion service; but when you look at the table in the impact assessment, it turns out that that is a headcount number driven by a number that is not a whole-time equivalent. However, for all the rest of the workforce, a whole-time equivalent number appears to be shown.

It would be good to nail down what the incremental requirement will be for psychiatrists, year by year and on a whole-time equivalent basis, so that between now and Report, colleagues can consider what the ramifications of that might be for a backstop on implementation. If that incremental requirement could be juxtaposed with what the Government think the organic increase will be in the number of psychiatrists over that period anyway, driven by the already published NHS workforce plan, that would be supremely helpful.

Mental Health Bill [HL]

Lord Stevens of Birmingham Excerpts

Committee stage
Monday 27th January 2025 Lords Chamber

[Lord Bradley (Lab)]

My Lords, I shall speak to Amendments 96A to 96C and 163A in my name in this group. They deal with the transfer of prisoners from prison to hospital in a specified timeframe of 28 days. I am obviously pleased that this has been included in the Bill under Clause 35, but I briefly give some background.

I first recognised a need to incorporate a time limit in legislation in my independent report to government in 2009. At that time, the Department of Health had piloted a 14-day waiting limit with strong support from stakeholders to roll this out nationally, and I recommended this in my report. Although it was accepted in principle, it was not implemented. However, Sir Simon Wessely’s review picked it up again with a more realistic 28-day time limit, which was then included in the draft Bill and now in this Bill, ensuring a statutory requirement rather than relying on good practice guidance.

My amendments are therefore probing amendments to understand how the 28 days will work in practice—essentially, when does the clock start? First, Amendment 96A would replace the words “As soon as practicable” with

“No later than two days”.


HM Inspectorate of Prisons found that one factor contributing to delay was confusion around when the 28-day transfer period starts, with 34% of patients not referred on day zero of the 28 days. This amendment would ensure that the referral notice is made no later than two days after an initial request, therefore clarifying on what day counting begins.

Secondly, Amendment 96B would change “must seek to ensure” to “must ensure”. The scrutiny committee, of which I was a member, heard that “seek to ensure” is quite vague and open, and therefore recommended this amendment. I believe, as do many organisations such as the Prison Reform Trust, that the inclusion of “seek to” in the current wording of the Bill implies only an attempt to successfully transfer within the 28-day time limit, rather than it being the guaranteed outcome, save for exceptional circumstances. It would provide a clearer, more definitive commitment to adhere to a 28-day time limit for referral.

Amendment 96C would require that a specified, accountable person be appointed by the relevant referring body to ensure that the specified 28-day transfer period is met. While there are many agencies involved in arranging prison transfers, I am concerned that there should be a person to whom accountability is assigned. As it stands, the Bill lists in new Section 48A(3) the persons to whom the referral notice must be given—the notified authorities—but there is no person, agency or authority assigned, either with overall accountability or accountability for each part of the process. I believe that there is significant merit in creating a single role to help increase and assure accountability—for example, a dedicated official whose primary function would be to ensure efficient transfers with the ability and power to liaise and intervene at the most senior level where necessary.

The amendment would clarify accountability and support the desire expressed in the impact assessment to increase,

“accountability for all agencies involved in the transfer process to meet”

the deadline. This was supported by Sir Simon Wessely’s independent review, which stated that it would help

“unblock the institutional barriers and … give … the teeth it needs to push the transfer through”.

I absolutely agree with this, and I hope that the Minister will too in his conclusion to this debate.

Finally, Amendment 163A would require the Government to publish guidance on what counts as “exceptional circumstances” specified in new Section 48A(4) and (5), as inserted by Clause 35. That provision provides for a 28-day transfer period for acutely mentally ill patients held in prison to be transferred to hospital. Examples are given in new subsection (5) of what exceptional circumstances are not, for example:

“a shortage of hospital accommodation”

or

“a shortage of hospital staff; unless occurring as a result of other exceptional circumstances”.

This amendment would provide an opportunity to clarify what does constitute exceptional circumstances. This would help to avoid doubt, confusion and subjective judgment over what may or may not be an exceptional circumstance and to help ensure smooth and efficient transfer. Again, I hope the Minister will be able to respond positively to that, perhaps with examples of what are exceptional circumstances.

Finally, I just note that, for transfers to be successfully completed in the 28-day time limit, the Government must ensure that appropriate bed provision in psychiatric intensive care units and secure care settings in every geographical area of the country is developed, together with a skilled workforce. I am sure that we will return to this topic at a later stage in our debates.

In conclusion, as I mentioned earlier, it is 16 years since I made my proposals on transfers, and I hope that that they are now coming to fruition. I am grateful to the Government for that and for not trying my patience any longer.

[Lord Stevens of Birmingham (CB)]

My Lords, like the noble Baroness, Lady Murphy, and the noble Lord, Lord Bradley, I too support the aim behind Clause 35, which is to ensure the speedy access to specialist mental health support for people in prison. Like the noble Lord, Lord Bradley, I also think that there is great merit in his Amendment 163A, which seeks to ensure that the Secretary of State produce statutory guidance on the definition of what will count as exceptional circumstances for the reasons that the noble Lord has given.

The Explanatory Notes give examples of what might count as an exceptional circumstance where the 28-day standard would not apply: prison riots, hospital floods or exceptional clinical reasons. Those are three examples, but it would be good to see more precision on this question because, as the Government’s Delegated Powers Memorandum says, the meanings of these words will be litigated. They will show up in judicial review and private law action. Therefore, the clearer the Government are prospectively, the less frictional cost and time there will be through the justice system and health system in giving effect to the new standards that are set out here in what hopefully will become the Act.

However, having supported the noble Lord, Lord Bradley, on that amendment, I will disappoint him now by just injecting a note of caution on his Amendment 96B. As we have just heard, it would leave out “seek to” in respect of delivering on the 28-day standard; excising those words, as he said, would in effect make it an overarching requirement—a “must”—even if there is a shortage of hospital accommodation or no staff available.

If the thought behind this is that the principal drivers of delays are essentially administrative processes then a “must” on 28 days can, in a sense, be given effect without a downside. But I wonder whether we actually have sufficient evidence to know that that is the root cause of such delays as occur. As I understand it, about four-fifths of the transfers from prisons to our specialist mental health facilities in the first half of the current financial year were to psychiatric medium-secure units and psychiatric intensive care, both of which are in very high demand and incredibly expensive resources, with highly constrained supply.

The impact assessment rather glosses over this question. When describing whether this new standard for transfers to hospital from prisons might introduce additional cost, it says at paragraph 169:

“Costs for the measure have not been monetised because they are principally driven by wider systematic changes which are supported by the legislation”—


that is, its administrative friction. It goes on to say something which I do not quite understand. I would be grateful if the Minister could interpret for us what the department meant when it wrote that an additional reason the costs were not being monetised was to ensure that

“resources are available to achieve transfers within the time limit in a greater proportion of cases”.

What are these “resources available to achieve transfers”? Are they additional or substitute resources? What is the scale of them? What was meant in the drafting of that paragraph?

My hypothesis is that this is not just about administrative friction. It is actually due to constraints on the supply in expensive and specialised mental health services, and therefore the unintended consequence of mandating, through excising “seek to” and making 28 days a trump card for people coming from prisons, would be one of three consequences.

Prisoners with severe mental health needs would find themselves in unsafe and poorly staffed facilities; or, by virtue of being in prison, you would displace a non-prison-based mental health patient who might have higher needs, as that is what the statute requires; or, under the Clause 49 powers, you would, effectively, see the Department of Health using the Henry VIII power, which it has in this Bill, to quickly rewrite 28 days and make it 180—or something else—because, as the delegated powers memo said, it might do so in that circumstance

“where insufficient beds are available to meet demand over a sustained period of time”.

For all those reasons, there may be unintended consequences of Amendment 96B which require further scrutiny.

However, in the spirit of wanting to make this work practically, I have laid down Amendments 97 and 98, which, essentially, as the noble Baroness, Lady Murphy, said, look to reciprocate the 28-day requirement. If you are aiming to get prisoners transferred to mental health facilities in 28 days or, similarly, when their treatment is complete, one should expect that the Prison Service or Immigration Service will ensure the return the prison estate to free up those scarce and specialist beds for other prisoners or patients who require treatment.

In a way, my amendment is a very gentle one. All I suggest is that if there are people stuck in specialist mental health beds who ought to be being returned to prison, that would constitute an exceptional reason for being unable to accept new intakes of prisoners being transferred. The reason this is such a gentle amendment is, of course, that the Government pray in aid the June 2021 best practice guidance for the transfers, which says that, although it should be a 28-day standard for moving from prison to mental health facility, it should be 14 days if moving back the other way to free up the bed. I have not proposed a 14-day requirement on the Prison Service, just the reciprocal 28 days, so, in that spirit of joint working, I hope these amendments will find wide support.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, briefly, I am with the noble Lord, Lord Bradley, as opposed to the noble Lord, Lord Stevens, on the “seek to” question. When I read Clause 35, I was very excited about what it promised; I thought that, at last, this was being taken seriously. I talked to a range of people who worked in criminal justice, and they said: “Oh, it is not going to happen; what are you excited about?”—they just did not believe it. At Second Reading, I cited Richard Garside from the Centre for Crime and Justice Studies saying that Clause 35

“while welcome, feels aspirational rather than practically implementable in the current system”.”.—[Official Report, 25/11/24; col. 549.]

I started to look at it again and thought that the danger for those of us who are following this debate is that we get bought off by this aspiration, and that, in practical terms, it will not mean what we all thought it was meant to. I am quite keen that we toughen up the statutory requirements.

--- Later in debate ---

Amendment 163A, tabled by my noble friend Lord Bradley, would ensure that Clause 35 is commenced only when the Secretary of State has clarified the meaning of “exceptional circumstances” and guidance on that definition is laid before both Houses. If we were legislatively to define exceptional circumstances, it would severely restrict our flexibility to update the definition based on an ever-evolving array of patient needs, which would be likely to delay implementation of the 28-day statutory transfer time limit while the definition is coined. As the noble Baroness, Lady Tyler, and the noble Lord, Lord Stevens, pointed out, cross-agency work to support the implementation of this provision has led to a greater understanding of the barriers to meeting the 28-day timeframe. It has revealed the systematic barriers and the scale of the challenges, which include workforce, bed capacity and estates, which is why we intend to commence this provision after 18 to 24 months and are seeking additional funding to support this ambition. I hope this provides reassurance, and I urge the noble Lord—

[Lord Stevens of Birmingham (CB)]

Can I just make sure I heard the Minister correctly? I think he said the that one of the reasons it would not be appropriate to do as the noble Lord, Lord Bradley, suggested—that is, to set out a statutory definition—was because it would take too long to do it and would delay implementation of the 28-day standard. I think he now just said it is intended that that will come into force in 18 to 24 months, the implication being that he thinks it would take 18 to 24 months to produce a piece of statutory guidance about what constitutes an exceptional circumstance. Is that correct?

[Lord Timpson (Lab)]

Having been in discussions with colleagues over the past couple of weeks on this point, I tested with them the processes involved in making sure that we can make this as robust as possible. One of the issues surrounding exceptional circumstances is the need for flexibility so that some of our professionals do not unwittingly break the law in exceptional circumstances. I am happy to write to the noble Lord with further details.

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[Baroness Barker (LD)]

My Lords, this is an interesting collection of amendments. I suggest that they are all slightly flawed but with good intent behind them.

In relation to Amendment 99 in the name of the noble Lord, Lord Kamall, as members of the scrutiny committee will know, we spent a long time talking about what happens in A&E departments. Our committee was very lucky to have Rosena Allin-Khan as a member; she is not just the MP for Tooting but a practising A&E doctor at St George’s Hospital. When we were wandering off into theoreticals, she managed to drag us right back to what actually happens.

The key issue that we returned to, as a committee, was that no matter what the police’s formal position is about their involvement in mental health crisis treatment, they will be there. First, people will go to A&E because the lights are on and, secondly, some of them will be very distressed, so members of the public and members of staff will expect the engagement of police officers. A lot has been said about the particular legal status of somebody who is detained in hospital. They are not technically detained, because they are not in a mental health facility. Yet we know that there is a need for spaces within A&E that are properly built and staffed as safe havens for a time, so that somebody who arrives in a state of distress can be in an appropriate place where they can become calm and, therefore, not be taken off inappropriately into the criminal justice system.

I can see what the noble Lord’s amendment is getting at. It deals with it in a very partial way. Following our discussions, and the discussion we had the other day with the noble Baroness, Lady May, on her amendment about police involvement in crisis moments for people with mental health problems, I hope that we might be able to come up with an amendment which is a bit fuller than the one which the noble Lord has put forward.

Amendment 137, the second in the name of the noble Lord, Lord Kamall, is about monitoring what is being done about the use of illegal drugs and substances in mental health services. I listened carefully to what he said. Does he think that this does not happen already? I have been to a number of acute mental health services in London. It is clear that staff have to deal with very difficult situations. This cannot be an issue that does not happen; it must be part of the daily risk assessment of anybody working there. Does the noble Lord think that it is extensive enough to warrant this kind of reporting and is this another legal duty that we want to put on staff? Is it the best use of their time, compared to other things? I am in no way against getting good data out to solve problems, if that is the best way to do it, but I am not entirely sure that his amendment does that.

The noble Baroness, Lady Bennett of Manor Castle, is absolutely right to focus us again on a question that we have never had answered since 1983, about which resources go into acute services and which into community services. When we have a legal change, as we did in 2006 with the move to community treatment orders, what happens to the flow of resources? Crucially, what is the impact? We just do not have the answer. We have a health system which is very good at delivering itemised care. I suggest that it does not actually deliver that many care pathways. Even when it does, I have never seen any clear evidence that patient information and money flows are sufficiently sophisticated to explain to us whether any of the policy intents that we want to see—that all noble Lords who have ever spoken on mental health in this place have wanted to see—will come about. Her amendment may not be perfect either, but I certainly support the noble Baroness and her intent.

[Lord Stevens of Birmingham (CB)]

My Lords, I also support Amendment 151 from the noble Baroness, Lady Bennett. Whether such reporting should be specifically confined to community mental health services or be more expansive than that is obviously for debate. Whether it should be bi-annual or more frequently, or once a Parliament, does not really matter. The point is to try to continue to put a spotlight on the gap between need and availability in mental health when, for all the reasons that we have talked about, there is sometimes a tendency to downplay that aspect of health and what the health service does.

As the noble Baroness said, if we cast our minds back to last Wednesday when we had that debate about whether the apparent increase in demand for children and young people’s mental health services was real or not, it was paradoxical that, later that evening, the embargo dropped on the Lancet Child & Adolescent Health paper on mental health. It showed that there had been a genuine and unparalleled increase, particularly in younger women’s needs for specialist eating disorder services. Having young people who are severely ill is not an artefact of culture.

Having those kinds of data brought together in one place and published with the imprimatur of the Government would be helpful, rather than as a sort of periodic post-election exercise of the sort that the noble Lord, Lord Darzi, provided. He, of course, also drew attention to the gap that exists between need and the availability of mental health services. I think he used a figure from April 2024 to point out there were more than a million people waiting for mental health, learning disability and/or autism services, of whom 345,000 referrals had waited longer than a year and 109,000 of those were for children and young people under the age of 18. There is a real gap here and a need to continue to put the spotlight on it, to mobilise attention and resource. I welcome the spirit behind Amendment 151.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, I have spoken a lot about the dangers of medicalising ordinary life and giving it a mental health label. The contribution I made in the previous Committee day on ADHD managed to get picked up by newspapers and generally cited as, “Cruel Baroness hates everybody that says they have ADHD”, so I have become even more infamous.

I welcome the call by the noble Baroness, Lady Bennett, for a review, because the more information and data we have about what is available in the community, the better. My only word of caution is that we should also recognise that, although we need more data, sometimes that data can be used as part of an advocacy for more resources and that data can be unreliable. My only caveat is that whatever the review does, it should not just take superficial headlines or self-diagnosis and self-ID as the truth, and that we should have some scepticism in that regard. We are going to have to understand the implications of this Bill when it is enacted for community care and provision. Therefore, I would welcome any attempt at getting to grips with the reality of that.

--- Later in debate ---

[Baroness Barker (LD)]

My Lords, Amendments 117 and 125 in this group are in my name. I tabled them in part to reflect what happened during the work of the scrutiny committee. We had long discussions about the benefits of ACDs, which were originally brought in under the Mental Capacity Act. I speak as the person who spent an awful long time trying to get them into that Act. They were brought in in the face of some resistance from practitioners. In fact, they have worked extremely well. It has been helpful to both patients and practitioners to know in advance, particularly for people who may have fluctuating illnesses, what it is that they want to do.

I point out yet again to the Committee that often, these are referred to as a decision to refuse treatment, but they are not always that. In the case of some advance choice decisions, people may say to their healthcare providers, “At the moment I am well. I know that, when I am ill, I may try to refuse treatment, but I want you to override that; I want you to carry on the continuity of my care”.

My amendment reflects something we were told. It will be no surprise to people that the noble Baroness, Lady Finlay, drew attention to the work that has been done in palliative care not only to make sure that people are aware of their right to make an advance choice decision about what they may wish to happen to them as their care continues, but to make it electronically. That was found to be one of the biggest barriers for practitioners, who would say, “We were in a crisis, and we couldn’t see it”. A lot of work has been done within the palliative care world to bring in new standard ways of doing things electronically. There is a pilot going on with the assistance of a private company, Thalamos—I think King’s has been trialling it—and it has so far been found to be extremely successful.

On a very prosaic level, the noble Earl, Lord Howe, is absolutely right that the more that patients feel empowered, particularly in mental health care, the better they do. There are also rather simple things: it takes a lot less time on the part of staff to read the stuff and not to be for ever filling in endless bits of paper. There are time and money efficiencies that can be put into front-line care.

All I ask is that, in addition to what the noble Earl, Lord Howe, said, we go one stage forward. Let us be honest: some mental health patients can have quite chaotic lives and they might not be the most tech savvy, but they need the same opportunities as anybody else to get on to a system that we know works and which needs to become the default position for all practitioners, rather than, as it is at the moment, an aspiration.

[Lord Stevens of Birmingham (CB)]

I strongly support the amendments in this group, particularly that in the names of the noble Earl, Lord Howe, and the noble Lord, Lord Kamall. I share the concern, as I think I mentioned at Second Reading, that as currently drafted this proposition could amount to an unenforceable, verging on vacuous, set of requirements, be it noticeboards or helplines. I very much hope that, between now and Report, Ministers will look to adopt the alternative proposition that the noble Earl, Lord Howe, has put forward. If, for whatever reason, that is not the case, I hope that collectively we might return to the question.

I have two small further points. I think I am right in interpreting the Bill as saying that guidance will be issued as part of a Section 118 code of practice which will give clarity on the duties of ICBs and NHS England in relation to the ACD part of the new Bill. I hope that that will, among other things, specify in more detail the categories of people who must be offered an ACD in accordance with the new statutory right which we will, I hope, have created; by whom the offer may be made; the fact that it should be recorded digitally, for the reasons that the noble Baroness, Lady Barker, has set out; and a number of other elements. Expecting individual ICBs to figure it out is a recipe for a subtherapeutic dose, shall we say.

My third and final point is that early evidence suggests that if the benefits described in the impact assessment come to fruition in the real world then there will be a positive impact, including on reduced compulsory admissions. Admittedly these are small and non-UK studies, as the material makes clear, but there is nevertheless a case for getting on with ACDs at scale, if the benefits that are hypothesised might actually be obtainable. It is therefore surprising to see in Annex C III of the impact assessment the suggestion that ACDs will not actually come online until 2029-30. It will take relatively marginal additional staff costs and time to do this, for a relatively small number of people. The suggestion is that it will be a surprisingly precise 55,071 people who might get a new ACD in 2029-30 and about 8,000 people who will get an updated one. These are not huge volumes, and we may be under-egging the pudding, but if the benefits are potentially there to be had, why on earth should we assume that we do not get going on this until 2029-30?

For all those reasons, I support the amendments in this group, particularly that from the noble Earl, Lord Howe, and the noble Lord, Lord Kamall.

[Lord Davies of Brixton (Lab)]

My Amendment 121 seeks to add financial circumstances to the advance choice documents. I spoke in the last session of the Committee about the importance of the link between financial problems and mental health problems. I draw attention again to work that has been undertaken by the Money and Mental Health Policy Institute, which suggested this amendment, and declare that I am a member of its advisory committee.

It is very welcome to see, in Clause 40, that health commissioners will have a duty to ensure that services inform people about advance choice documents. I listened to the speeches of the noble Baroness, Lady Barker, and the noble Earl, Lord Howe, about extending the reach of these documents. I very much look forward to the reply from my noble friend the Minister, because they sounded pretty convincing to me.

Ensuring that everyone has access to an advance choice document is something that the Money and Mental Health Policy Institute has called for previously. We believe that this clause must go further to advance a specific prompt about people’s financial situation. It may seem a small matter, but for people who have been detained under the Mental Health Act, who are possibly too unwell to keep themselves safe, finances are understandably often the last thing on their mind. As I mentioned in a previous session, this does not stop bills needing to be paid, debts mounting and collections activities being escalated. Including a section on money in the document would help people have greater choice and control over their finances when they are in crisis.

A person recalling their experience of receiving treatment for their mental health shared this comment with the Money and Mental Health Policy Institute:

“I was never asked if there was anyone who was opening mail and keeping on top of my day-to-day living stuff … It’s always the same. I go in for treatment and come out to find my financial world is in a bigger mess than when I went in. The resultant terror, shame and guilt undoes all the work of the treatment and I am back in crisis again”.


This section should include explicit prompts which encourage people to reflect on and stipulate their preferences around finances. That can include consideration of how priority bills will be paid; preferences around access to credit; and advance planning to identify and empower a third party to manage their finances on their behalf, such as a lasting power of attorney or third-party mandate.

By including a systematic consideration of finances in ACDs and offering explicit prompts, people can be supported to have greater control and choice. It would better enable healthcare professionals, as well as the individual concerned, to put in place preventive measures to safeguard individuals from the financial harm that can be caused by, and exacerbate, mental health crises.

As mentioned previously, this is not about requiring healthcare professionals to support people with financial advice, or to deal with issues they have neither the expertise nor the capacity to deal with. It is about empowering them to identify people in need and refer them to the appropriate existing support.

Mental Health Bill [HL]

Lord Stevens of Birmingham Excerpts

Committee stage
Wednesday 22nd January 2025 Lords Chamber

[Baroness Murphy (CB)]

I agree with everything that the noble Baroness, Lady Barker, has said. She is absolutely right that professions should be challenged, and that is partly what legislation can do, particularly in debates such as this. But we are losing the very important amendments from the noble Earl, Lord Howe, about young people and what we can do to improve circumstances through the Bill, and I want not to lose them, because they are very important.

[Lord Stevens of Birmingham (CB)]

Very briefly on the question that the noble Baroness, Lady Fox, raised, the notion of supply-induced demand is a well-known phenomenon across health services. However, I have to say to her that I think that we are a long way off that being the problem that is principally confronting children and young people’s mental health services. We have a massive gap between the need for effective therapies for children and young people and their availability.

When the process of trying to expand children and young people’s mental health services kicked off several years ago, the goal was that we would get to a situation where one in three children and young people with a diagnosable mental health condition would get some form of specialist mental health support. That number has now been exceeded. I was just looking at the stats published last week and, although I do not see the most up-to-date number for it, I would be surprised if more than one in two are currently getting specialist mental health support for a diagnosable mental health disorder, not just distress. So, we are a long way off confronting this problem of supply-induced demand, whatever broader cultural or therapeutic labelling questions that she rightly points to may be in the ether. Fundamentally, we are going to need more services to benefit the children and young people who need them, not pretend that this is somehow all vapourware, imaginary or a cultural deformity, unlike our predecessors in the Victorian era.

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

I thank noble Lords for their contributions on this important set of amendments. I say at the outset that I note the various observations that are outside the Bill, as the noble Baroness, Lady Barker, pointed out, but I have noted them and I am sure we will discuss them on a number of occasions.

First, I turn to Amendments 46 and 47, tabled by the noble Lord, Lord Kamall, and the noble Earl, Lord Howe. I have heard how many noble Lords are in support not just of those two amendments but all the amendments in the group. I am sure noble Lords will not be surprised to know that I understand where people are coming from and I will be pleased to go through the response to them.

The noble Earl, Lord Howe, spoke about “troubling and sensitive matters” and about being inspired by testimonies that came through the charity Blooming Change—I express my thanks to that organisation for the work it does. Officials in the department have met the group and it made a very helpful contribution. Hearing from those with lived experience is crucial to making sure that this is the best Bill, and I know that many noble Lords have done that, so I thank the noble Earl for bringing that into these amendments.

Amendments 46 and 47 would change the definition of appropriate medical treatment to include treatment which

“seeks to minimise the patient’s distress and promote psychological wellbeing and recovery from any childhood trauma”.

Childhood trauma can of course have a devastating impact on psychological well-being. Effective and compassionate in-patient care must be informed, as I have said, in co-production with people with lived experience and be trauma informed. NHS England’s Culture of Care Standards for Mental Health Inpatient Services certainly underlines this.

The noble Earl, Lord Howe, and other noble Lords raised concerns around in-patient settings and how appropriate they are, which I understand. I hope it will be helpful to say in answer that the new definition of “appropriate medical treatment” introduces the requirement that treatment has to have a reasonable prospect of benefiting the patient. We would expect the setting in which someone is going to be detained to be considered as part of this. Of course, I am more than aware—without wanting to go into the generics in this group or any other group—that the place in which we start, in terms of the suitability and availability of the right settings, is not where I am sure any of us would want to be.

We also know that the sensory environments in settings can cause difficulties for people with sensory sensitivities. To support NHS services to address sensory aspects of the environment, which the noble Baroness, Lady Bennett, referred to, NHS England has published a sensory-friendly resource pack, which outlines 10 principles to improve the sensory environment and signposts other resources.

The clause in the Bill that defines “appropriate medical treatment” already requires decision-makers to take into account the nature and degree of the disorder and all other circumstances, which could include childhood trauma, when considering whether medical treatment has a reasonable prospect of therapeutic benefit. The definition of medical treatment is unchanged and is indeed broad, including nursing care, psychological therapy and medication. All these interventions could include an overall aim to minimise distress and promote psychological well-being.

Amendments 50 and 51, tabled by the noble Baronesses, Lady Tyler and Lady Bennett, aim to ensure that the clinician considers non-drug-based interventions as part of the new “clinical checklist”. The checklist requires clinicians to identify and evaluate alternative forms of medical treatment when deciding whether to give a particular medical treatment to a patient. As I have already mentioned, the definition of medical treatment under the Act is broad. As well as non-drug-based interventions, it includes specialist mental health rehabilitation and care. On the point raised by the noble Baroness, Lady Bennett, which is an important one, it does include the therapeutic environment or setting. This requirement, as outlined, would apply to all patients falling under Part IV of the Act. It includes patients with a learning disability and autistic patients who are detained for assessment under Section 2 and patients detained for treatment under Part III.

With specific regard to those with a learning disability and autistic people, I recognise the concern that they are more likely to be prescribed an antipsychotic than the general population. I emphasise that psychotropic medication should only be given for the right reasons, in the lowest dose, for the shortest time. NHS England has a national programme of work to stop overmedication and the inappropriate prescribing of these medications, which is aimed in particular at people with a learning disability and autistic people. Noble Lords will be aware of the STOMP programme. Alongside it is a national supporting treatment and appropriate medication in paediatrics programme called STAMP—the two are not to be confused. These programmes work particularly closely with those with lived experience, families and carers organisations, and a wide range of health and social care professional bodies.

Amendment 53, in the names of the noble Earl, Lord Howe, and the noble Lord, Lord Kamall, would require the approved clinician to offer a patient any treatment that is appropriate, having applied the new clinical checklist. The reference to medical treatment in that checklist should already be read in accordance with Clause 8, which inserts a new definition of appropriate medical treatment to enact the principle of therapeutic benefit.

The clinician must also support the patient to participate in decision-making to make sure that they do not simply offer their preferred treatment to the patient, with no discussion or consideration of alternatives. The Bill also requires clinicians and, where relevant, the second opinion appointed doctor to provide a written record that the treatment being administered meets the definition of appropriate medical treatment. Therefore, it is felt that the Bill already meets the intention of this amendment. Furthermore, if the intention is to ensure that a range of treatments is being considered by the responsible clinician, I can reassure noble Lords that this is already the case, because, as I have said, the definition of medical treatment is broad.

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[Lord Meston (CB)]

My Lords, I understand the dilemma. The point I emphasise is that, in deciding this, one has to be clear that the child has a proper explanation of the ultimate decision that has to be made. It is to that end that the competence has to be assessed.

[Lord Stevens of Birmingham (CB)]

For those of us who are not anywhere near as legally expert as the noble Lord whose wise deliberations we have just heard, could he clarify the amendment that talks specifically about ring-fencing this new test for the Mental Health Bill? To what extent would that be consistent or not with, for example, the ruling of the Court of Appeal in Bell v Tavistock—the NHS trust—in the case of puberty blockers, which concerned the interpretation that the High Court had given to the Gillick test?

[Lord Meston (CB)]

I am tempted to say that I really do not know. That was a faster ball than I expected to receive. I think the answer is that the case law would be consistently applied, even as it stands now, but would undoubtedly be aided by a statutory test. Whether it would apply in cases such as that which the noble Lord just mentioned, I do not know. The purpose of the amendment is to provide a test for decisions that have to be made consequential upon this legislation, not other situations.

Mental Health Bill [HL]

Lord Stevens of Birmingham Excerpts

Committee stage
Tuesday 14th January 2025 Lords Chamber

[Baroness Murphy (CB)]

I would say that all mental disorders are different but that they cannot all have their own Acts of Parliament. I do not accept that autism is different. Of course, it is different in the way that it manifests—

[Lord Stevens of Birmingham (CB)]

I will make a slightly cheeky intervention, if I may, on the noble Baroness. I am not weighing into the debate that is taking place but simply make this point. Does she accept that the fact that a condition is listed in the DSM or the ICD is not itself definitive? Until 1973, homosexuality was listed as a psychiatric condition in the DSM and until 1990 it was, I believe, included as a psychiatric diagnosis in the ICD. Therefore, that is not the strongest evidential basis for her claims.

[Baroness Murphy (CB)]

I agree with the noble Lord, but the reality is that we use DSM-3 and ICD-11 in the international classification of disorders. If we in Britain are to go outside that, for reasons of our own, then we had better have some pretty good ideas why that should be. I am not so sure that we have them.

The Wessely review rejected the notion because, as the noble Baroness, Lady Berridge, said, it carried serious risks that individuals would be extruded and neglected, the opposite of what is intended. Similar anxieties were expressed in the development and creation of other Acts—I am sorry that I am going to go on longer than the advisory—so as not to exclude anybody from this group, because we want mental disorder to be an inclusive thing and not to exclude whole groups of people. Their protections are gone if we exclude them.

I accept that almost all the developments for autism and learning disabilities in the Bill are very positive. They will really improve the way that people think about autism and will have an extremely beneficial effect on trying to develop services and improve training, but there is no evidence that changing the criteria under the Act will do anything to improve it. Getting money into services and service design is what we need and not a change in the legislation for criteria. As the Royal College of Psychiatrists’ group of specialists in learning disabilities have pointed out, the vast majority of them do not want this change in legislation. We should think very carefully before we submit people to something when we do not know what will be unleashed as a result.

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[Baroness Watkins of Tavistock (CB)]

My Lords, I support the amendment in the name of the noble Baroness, Lady Barker, with relation to housing. I do not want to go back 20 years for any reason except to say that, when we were closing the vast majority of mental health in-patient beds, the main aim of many of us doing those change programmes was to ensure that people had somewhere to live when they had been living in hospital for 10, 20 or, in some cases, 30 years, and that the housing had to be appropriate to their level of ability. Spending 30 years in a hospital does not exactly teach you self-reliance. There are some real challenges about that, so housing must be considered in any discharge planning.

On Amendments 19 and 20, the noble Baroness, Lady Hollins, has sent me a copy of her speeches in her absence. Like others, I think that it shows her commitment to this House that at this point in her life she is trying to make sure that her voice is heard. I add my condolences to those of others in the Committee. Her point is that you would not discharge people from acute hospital without some proper care and treatment plan. I want to use my own words rather than hers, but when you say that somebody needs dialysis or that they need regular checking of their heart monitor, we automatically do it. Elective care is still getting a huge amount of focus, but elective care in this country is defined as acute hospital care, not elective care for mental health patients and people with learning disabilities. I want to rest it there, but that is why I support Amendments 19 and 20 so strongly.

[Lord Stevens of Birmingham (CB)]

I too am supportive of the spirit and intention behind Amendments 19 and 20, but I want to raise two textual questions relating to whether they would give effect as was intended.

In respect of Amendment 19, I am not sure that the explanatory statement accurately characterises what the amendment proposes. It says that the amendment ensures that ICBs and local authorities would

“have a duty to carry out”,

whereas at the point at which those words would be inserted it appears that the duty would also then fall to the patient’s responsible clinician. Amendment 19 by itself would essentially see CETRs overriding the judgment of the responsible clinician, which I think is quite a significant step to take.

In any event, I wonder whether Amendment 20 undoes any of the good work that Amendment 19 proposes in the first place. It says that you can ignore the exhortations of Amendment 19 if there is a “compelling reason” to do so. My question to the drafters of Amendment 20 would be: what statutory interpretation should be placed on “compelling reason” and how might the courts be expected to adjudicate in the event of judicial review?

[Lord Bradley (Lab)]

I support and have added my name to Amendment 13, tabled by the noble Baroness, Lady Tyler, around communication issues. As she rightly pointed out, this could have been linked to Amendment 2, which has already been debated at some length. I will not repeat the same arguments, but they apply to this amendment, which is why I support it.

I also very strongly support the amendment on housing tabled by the noble Baroness, Lady Barker. I am chair of NHS England’s health and justice advisory board and have worked on the development of RECONNECT, the service to support people coming out of prison back into the community, which is very much a health-based initiative. Unless their housing needs are met at that point, their treatment, their support and their care plan can fall apart very quickly. Consequently, they are very quickly back in the criminal justice system. The same comparison can be made with this amendment. I strongly support housing being at the core of all issues relating to health and social care.