Mental Capacity (Amendment) Bill [ Lords ] (Fourth sitting)

Alex Cunningham Excerpts

Thursday 17th January 2019 Public Bill Committees

[Barbara Keeley]

Paragraph 21 of the new schedule AA1 makes provision for certain people to be excluded from carrying out the pre-authorisation review of a liberty protection safeguards application. In this section, the Bill specifically prohibits pre-authorisation reviews from being carried out by anybody involved in the day to day care of the cared-for person or in providing any treatment to the cared-for person. We are glad to see the safeguard is in the Bill. It would not be appropriate for a paid member of care staff to be the independent person safeguarding a person’s liberty as well.

We have previously discussed the issue of conflict of interest and we have tabled amendments to eliminate this, but the safeguards are still fallible. We have tabled amendments 35 and 36 because we believe the Bill requires further clarification to ensure that the independent reviewer is not in any way connected with the organisation conducting the pre-authorisation review. We are concerned that it is not only people directly involved in providing care or treatment to a person who may be incapable of providing that truly independent check we want to see. There are other individuals, for instance, within the same care home provider, who would still lawfully be allowed to conduct a pre-authorisation but who could not be described as truly independent. That would still represent a wholly unacceptable conflict of interest. It would be a shame if, having accepted the principle that there must be no conflict of interest in this Bill in relation to care home managers, the Government allowed it to creep in via the back door, in this way.

Amendment 36 is designed to address further potential conflicts of interest in cases where the cared-for person is held in an independent hospital. I raised the real concerns from across the sector, both on Second Reading and earlier in Committee, about the potential relationship between independent hospitals and the approved mental capacity professionals who will review cases. Our concern is that there is nothing to prevent an independent hospital from entering into a cosy relationship with an approved mental capacity professional. The AMCP could then review the cases going through that independent hospital, effectively removing a vital safeguard against the improper deprivation of liberty.

The Government have repeatedly said that that would not be permissible under their proposals. Our amendment attempts to clarify the position, so that stakeholders and others can be reassured that the Bill will have its intended effect. The Minister’s agreeing to the amendment would be welcome, given the speed at which the Bill is progressing and the concerns raised by stakeholders about not only the contents of the Bill but the perfunctory way that stakeholders have been consulted.

The Bill was amended in the Lords to ensure that nobody with a prescribed connection to a care home can carry out the pre-authorisation review. The Minister said that the Government will bring forward regulations in due course that will set out the different kind of relationships to a care home that will be prescribed. I have already made some comments on that, which I will reiterate briefly. It is important that the Government take a broad view of the relationships that should be prescribed and, indeed, proscribed. These few lines are in fact some of the most important safeguards in the Bill.

[Alex Cunningham (Stockton North) (Lab)]

It is a pleasure to serve under your chairmanship for the first time this afternoon, Mr Pritchard. Opposition Members have expressed very real concerns about the additional responsibilities placed on care homes by the Bill and have questioned how that can work, particularly in situations in which there might not be a care home manager or if the care home management might be considered inadequate or not fit for purpose.

The Bill would allow care homes to choose any staff who they consider appropriate to undertake assessments. Who will make those decisions? If there is no manager, who else will take the decision? If the manager is deemed incompetent and does not know how to run a care home, how on earth can they make a decision on an assessor? I cannot understand that.

One best interests assessor expressed worry that care homes will want to undertake assessments as cheaply as possible, so many independent reviewers will only be able to review documents, rather than actually meeting the person in care and/or their family. I cannot understand how the Minister or Government Members think that care homes and hospitals should not consult with a range of independent reviewers, rather than potentially just one.

As hospitals will be able to employ their own independent reviewers, is the title of “independent reviewer” misleading and potentially dangerous? They will have a vested interest in the future care of a patient, and care providers, with their well-documented financial pressures, will have an interest in retaining the people that they care for. Surely the Minister agrees that assessors should be completely independent from care homes or hospitals and not just independent in name only. Does she agree that we have to do everything we can to remove this conflict of interest?

Another best interests assessor told me at a December meeting of the all-party parliamentary group on social work, which I chair, that although most care homes practise with integrity, the new proposal leaves the system open to abuse. I know that it would only be the odd one here and there, but that is the odd one too many. Under strict time and financial pressures, care home managers are likely to keep recommissioning the same assessors who are sympathetic to the desires of the care provider. The Minister must agree that that is unsatisfactory and could effectively lead to a deprivation of liberty for the people in the care home.

If there is even a tiny danger of that because of the way the Bill is constructed, the Minister could be culpable for a person losing their freedom simply because, in some cases, “independent” turned out to be anything but. I know she will reflect on that, and I hope she will accept the amendment, but if she chooses not to, she must spell out exactly how she will ensure that some vulnerable person is not caught in a trap of her Government’s making.

--- Later in debate ---

[Caroline Dinenage]

I think that might just be my natural resting face. I understand what the hon. Gentleman is saying, but it depends who we are looking at. If the pre-authorisation review is being conducted by a local authority for a care home, the oversight of the senior members of the local authority would apply, as well as the Care Quality Commission, which deals with the quality of care homes. If it is something like a hospital, people will monitor other people’s work as happens already within hospitals, CCGs and health boards.

The Bill says that somebody who is involved in the direct care of a particular person cannot mark the homework of another person. In something as big and broad as a local health board, a CCG or a hospital trust, which can be enormous, exclusively saying that there could not be two people, who have never met each other before, looking at each other’s work seems to me a huge leap.

Amendment 36 is designed to prevent anyone with a prescribed connection to an independent hospital from conducting pre-authorisation reviews. I am sure that we can all agree that the pre-authorisation review is critical to the effective operation of the liberty protection safeguards in providing independent reviews of proposed arrangements that may deprive people of their liberty. We are talking about the most precious and vital of our human rights. The reviews have to be conducted by someone independent, who is not involved in the day-to-day provision of care or treatment of the cared-for person. That provides the necessary degree of separation to ensure that the model is compliant with the European convention rights.

By requiring authorisations in independent hospitals to be considered by an AMCP, regardless of whether the individual objects, we add a further level of security and build on other safeguards within the model. The AMCP will meet with the person, complete any relevant consultation and review assessments to decide whether the authorisation conditions are met. They can effectively veto proposed arrangements, if they feel that the proper conditions are not met. AMCPs will be professionals, such as experienced social workers, learning disability nurses and psychologists. Their practice will be regulated by and they will be accountable to their professional bodies—in answer to what the hon. Gentleman said earlier.

[Alex Cunningham]

The Minister just used the expression—I have lost my train of thought. I beg your pardon, Mr Pritchard.

[Caroline Dinenage]

I will take an intervention from the hon. Member for Worsley and Eccles South.

[Caroline Dinenage]

It is in there—it is in both. In addition we have the AMCPs. As I said when discussed amendment 19, I fully understand hon. Members’ concerns around independent hospitals. I know the hon. Lady shares my concerns, and this matter has been raised by Members across the House. I said to her, in relation to amendment 19, that I wanted to go away and consider it further.

[Alex Cunningham]

I did not realise I was going to have to declare an interest in the Bill, in view of my lapse a few minutes ago. My question is about the reference the Minister made to the AMCP always meeting the person. Does the AMCP meet the person in every circumstance? We tabled amendments because we want everybody to have access to that sort of professional person—not just for them to see a report, but to actually see the person.

[Caroline Dinenage]

Yes, by requiring authorisation in independent hospitals to be considered by an AMCP, we add that extra level of scrutiny and build those safeguards into the model.

Given that I have committed to look at independent hospitals again, as I said in relation to amendment 19, I hope that the hon. Lady is willing to withdraw the amendment.

--- Later in debate ---

[Barbara Keeley]

I agree, and it is words like those that we have a problem with. The Government have said that there will be guidance in the code of practice that will address what that means and what should be done in cases where it is neither “appropriate” nor “practicable”. The Opposition cannot yet see the code of practice and, therefore, we simply cannot accept assurances about its contents. The only way that we can guarantee that the Bill will work as intended is to put provisions in the Bill.

I made a point on Tuesday about the code of practice that I will repeat now, because it is an important one. Statutory codes do not exist without a statute, and the majority of laws do not have a code of practice. Codes are there only for when non-legal people are using a law directly. No one expects non-legal people to read or necessarily understand a statute, and so a code is provided. Such a code follows what is in statute and sets it out in lay terms and at length, but it does not exist if the obligation in law is not clearly set out. That is what we want to address. Where a case requires review by an AMCP, that professional should be required to carry out their review in the fullest manner possible, and that must mean that they meet the cared-for person.

If the Government want to set out the limited set of circumstances where they do not feel that that should be the case, they should do so in the Bill, as then we can give their proposals the scrutiny that they are due. This is not an issue that should be relegated to a code of practice. If the circumstances in which a meeting is not required are too broad, there is a risk that people will be inappropriately deprived of their liberty, despite having had a review from an approved mental capacity professional. That would be unacceptable. We cannot allow decisions of such importance to be made in a code of practice that we cannot see. As such, I hope that the Government will accept the amendment, and ensure that all the high-risk cases to which we are referring receive the full review that they need, including a meeting with the AMCP.

[Alex Cunningham]

I know that the Minister is well intentioned with this Bill, but it remains the case that the cared-for person is not always at the heart of it. That is a major worry, not just for us, but for people across our society. The issue has been brought to me by the Law Commission, by the Alzheimer’s Society, by experts who work for pro-liberty groups and by constituents who have taken the time to write to me on this point specifically.

It is baffling to me that the approved mental capacity professional is not required in the Bill to meet the cared-for person. Yet they are the professional who will decide the future of that person—whether or not they lose their liberty. None of us would want that for one of our relatives, would we? We simply would not want that to happen.

It may well be that the person in care does not have the capacity for a meaningful conversation to express their wishes and beliefs, but the assessor does not know that unless they meet them. It is essential. If the person in care does have some capacity, which I suspect would be identified by the assessor, surely their views, however communicated, ought to be taken into consideration—and, who knows, we might avoid the deprivation of liberty for that person.

I have already raised the importance of the role of speech and language therapists. I think the hon. Member for Faversham and Mid Kent mentioned them this morning, and I know the Minister accepts the role that they have to play. They may well help identify the wishes of the cared-for person simply by enabling them to communicate, and surely there should be a separate assessment of the person’s views. If they are opposed to the accommodation or the care plan, an independent advocate should act in that person’s best interest.

Evidence submitted by Rethink Mental Illness raises the important point that nobody should have an advocate forced upon them, especially if they do not want one. However, advocates should still be appointed, even if they are then removed. That would ensure that the opinions of both the advocate and the person in care are taken into consideration, and that a judgment is made by a professional on the need for representation. We will debate advocacy later on in this Committee and I will speak to it in more detail then.

Ultimately, the amendment is about ensuring that the approved mental capacity professional has met with all the appropriate parties, including the person in care themselves, so that they can make the most informed decision possible. Not only does mandating the AMCP to meet the cared-for person before making the decision ensure liberty and respect is given to the person in care; it makes the professional’s job considerably easier, as diagnosis is more effective when they have met the person. As was raised in the evidence-gathering, in some cases simply meeting the cared-for person can make it obvious whether the person has capacity. As I said earlier, I suggest that no one but a professional is fully equipped to make that judgment.

Kay Matthews, from the deprivation of liberty safeguards team in the Borough of Poole local authority, wrote to the Committee and said that she would like to see the

“Wishes of the person—past and present”—

I emphasise “past and present”—taken into consideration in the Bill. She went on to say:

“I would like the person’s wishes—what they want, what they would have wanted—to be central to the assessment. I would like it stipulated that people making decisions on behalf of the person ought to support the person who lacks capacity to make the decisions they would have made if they still had capacity; that the person’s wishes are to be followed unless there is evidence that there is or could be seriously dangerous or significantly distressing consequences for the person.”

Ms Matthews says that that is vital because,

“in practice, some staff and relatives see a lack of capacity as a green light to over-ride the wishes of the person to meet their own needs (which are usually to feel less personally or professionally anxious about the person).”

She says that in her 10 years of experience she has seen it happen “again and again”. It is not only ineffective, but potentially dangerous that the Bill would allow the AMCP to basically come up with a verdict by just reading the in-care person’s file or talking to everyone else apart from the person themselves. I understand that because of tight budgets and cuts, care homes need to save money and time, but that comes at the cost of the in-care person.

While I am on the subject of costs in care homes, can the Minister tell me what assessment she has made of the potential costs that will fall on care homes from their extended role in the process? Has she had any data from the industry on that and, assuming she has, will she publish that assessment and data so that the Committee can understand the additional financial burden she is placing on the sector? Can she also advise us of who will be responsible for those costs? Will it be the hard-pressed care home that has to absorb them? Will there be a charge on the individual if they happen to meet their own care costs? If they do not, will that pass to the local authority, the health board or the clinical commissioning group? Who will pick up those costs? If the Minister does not have the data, will she commit to getting some before Report stage?

Returning to the amendment, do the Government want to be seen to be ignoring the voices of people in care? Most of all, does the Minister want to see people in care deprived of their liberty for the sake of what I see as one essential step in the process? The Mental Capacity Act should be an Act that is designed to support, listen to and respect the opinions of those being cared for. It should not make it easy for other people to quash or ignore the decisions of that individual.

[Alex Norris]

I have specific trouble with the word “practicable”. From my time in local government—I know things have not got better in the 18 months since then—I would argue strongly that the current assessment workload is not practicable for the individual. Earlier in our consideration of the Bill, my hon. Friend the Member for Birmingham, Selly Oak compared social work case loads when he was active in the profession with what they might be today. Putting in legislation how practicable it is for an individual to go and do an assessment creates the chance of a loophole that does something that we do not intend the Bill to do.

It is striking, as my hon. Friend the Member for Birmingham, Selly Oak said, that the Minister has at all turns been careful about what has been put in the Bill so as not to create future loopholes. We know that traditionally, this area has been tested very heavily in case law and it will be tested again in court. She has been very careful not to put those words in there, but this one is problematic. We know that in a time of rising demand and diminished resources, there will be pressures. To put something in that suggests that if it is just too difficult for a social worker to go and do an assessment, that assessment will not take place, is dangerous. I do not think that is what we are trying to do. I believe that it will lead to a serious problem.

The market for providing very high-need care is not very developed. We are talking about very small numbers of people, so there are not masses and masses of providers. When it comes to all of us being older, there are facilities in all constituencies and communities for older people to have residential care, because it is a high-demand area. The very specific, individualised care packages that involve things such as depriving liberty are not found in every community. Often, we hear horror stories in children’s mental health of people being sent a long way away to find the right facility. Are we then saying that a reassessment might not be practical, because the AMCP is in Nottingham and the care placement is a long way out on the east coast in Lincolnshire? That might not be considered by an individual to be a “practicable” thing to do, so I have a real problem with that word.

If the Government are saying that there are circumstances—my hon. Friend the Member for Worsley and Eccles South mentioned the exchange in the other place—where they are relaxed about an AMCP not seeing an individual face-to-face, I think that is a bad idea, for the reasons detailed by my hon. Friend the Member for Stockton North. If the Government are saying that there are circumstances where they are relaxed about that, they should name them and put them on the face of the Bill and be exhaustive with them, so that we can be clear and test the will of the Committee as to whether we agree.

We need to have a greater sense of what we are saying in respect of dialling back people’s rights to see a qualified professional when they are having their liberty removed. If we are rolling that back, let us be really clear about how we are rolling it back—the exact circumstances and what recourse they might have if they or their carers believe that to be wrong. I think this is out of step with all the discussions we had on Tuesday and this morning. I believe it creates a loophole and we need greater clarification.

[Caroline Dinenage]

I thank those hon. Members who have spoken and tabled these amendments. Amendments 42 and 43, as we have heard, would require an approved mental capacity professional to meet with the person in every case where they are carrying out a pre-authorisation review, rather than—as we propose and as is written on the face of the Bill—where it is “appropriate and practicable”.

The Bill currently states that where an AMCP is carrying out a pre-authorisation review, they must meet with the person where practicable and appropriate. In the vast majority of circumstances it will be practicable and appropriate. This qualification comes from the Law Commission draft Bill, which recognised—we agree with this—that the AMCP will be required to meet with the person in virtually every case. This is an important protection within the liberty protection safeguard system.

[Alex Cunningham]

Will the Minister give way?

[Caroline Dinenage]

Let me make a bit of progress and I will hopefully answer the hon. Gentleman in the process, but if I do not, he can intervene again.

The exceptions where it would not be practicable and appropriate would depend on the circumstances of the case. Things such as workload, cost and distance would not count under the qualification of not appropriate or practicable. It might be not appropriate or practicable, for example, where the person is in a coma and the family has requested that the AMCP does not interview the person, because it would cause distress. Another example is where someone at the very end of their life needs to be deprived of their liberty in their last few days, and they do not want to see an AMCP. In many cases, we feel it would not be appropriate to override the person’s best interests and force them to meet with an approved mental capacity professional.