Mental Health Bill [HL]

Baroness Fox of Buckley Excerpts

2nd reading
Monday 25th November 2024 Lords Chamber

[Baroness Fox of Buckley (Non-Afl)]

My Lords, it is somewhat humbling and not a little intimidating to follow so many insightful speeches from those at the heart of the issue. For me, as a bit of an amateur outsider, I broadly welcome the Bill, with some reservations that I will pursue in Committee.

For Second Reading, I suggest that we should always remember the cultural and political context of our deliberations and indeed definitions—I will come back to that. We also need to remember the lessons of history: locking people up for mental illness has been mired in ethical and political scandal over many years. We all can cite the former Soviet Union, where political dissidents were labelled mentally ill, but even in democracies it was not until 1973 that the American Psychiatric Association voted to declassify homosexuality as a mental disorder—and let us not forget those unmarried mothers who were sectioned in the 20th century.

However, even with this misuse of psychiatric power, it is still possible to be a defender of liberty—such as myself, I hope—and yet acknowledge the need for some people to have their liberty restricted because of their mental health. Many years ago, when I worked for Mind, this was a very polarising debate; but I argued then, and continue to believe, that when someone is severely psychotic, manic or out of their mind, psychiatric coercion is not a violation of individual autonomy. That is because the subject at that point in time—“at that point in time” is key—is not autonomous in any moral sense.

However, is release not different? And that brings me to the issue of community treatment orders. Along with others, I too would like them to be abolished. The general problem of CTOs was well explained by Dr Ken McLaughlin is his pamphlet Escaping the Straitjacket of Mental Health. In it, he makes the point that, while the case for compulsion can be justified at the point of hospital admission, when the patient is likely to be in an acutely psychotic state, can compulsion be justified at the time of hospital discharge when the patient should have mental capacity restored? Prior to 2007 and CTOs, on leaving hospital, an ex-patient regained their full rights of citizenship, including the right to refuse medical treatment. The problem of being released with a CTO is that you return to the community as neither a patient nor a citizen. This hybrid state is troubling in terms of compromising civil liberties.

I tend to agree with the noble Earl, Lord Howe, and others: at the very least I question why the Bill will allow indefinite CTOs to occur. I agree with the Centre for Mental Health’s call for the safeguard of time limits, and then CTOs could be extended only if there was proof of proportionality for the individuals concerned.

The question of indefinite “coercive orders” inevitably reminds us of the plight of the almost 3,000 prisoners held indefinitely behind prison bars under the abolished and discredited IPP sentence. Many of these people are incarcerated in prisons precisely because their mental health has deteriorated as they have been refused release, even on licence; a sort of unacknowledged section is happening here. What is more, shockingly, a wide range of experts now blame this very sentencing regime as the cause of IPP prisoners’ mental distress. The hopelessness—“psychological terror”, as it has been described—of never-ending sentences has literally driven prisoners to lose their minds, and even their lives through suicide.

So, while I am delighted the Bill will remove prisons from the list of places of safety, how does it help IPP prisoners? They are deemed too mentally unwell to be released safely. Their illness is derived at least partly from a shameful state mistake, yet IPP prisoners are coercively detained indefinitely in institutions that the Bill would have the state now deem as unsafe for those with serious mental illness.

One case that has recently attracted headlines illustrates an IPP prisoner’s plight as it relates to the Bill. Forty year-old Thomas White has served 12 years as part of his indefinite IPP for a non-violent theft of a mobile phone in 2012. According to his psychiatrist, Thomas developed his religious hallucinations and psychosis as a direct result of being on an IPP sentence. His sister Clara has been campaigning for over a year to have Thomas transferred to a hospital, but his recent assessment appointment was cancelled due to staff shortages. Clara notes despairingly:

“We waited a long time to have Thomas assessed again by the psychiatrist. We more than likely won’t get the assessment again. The system is nothing but criminal—people like my brother are being seriously failed”.


James Frith, the Labour MP for Bury North, agrees. He said:

“Thomas’s indefinite imprisonment has had a hugely detrimental impact on his mental and physical wellbeing. Thomas should be a patient, not a prisoner”.


Hear, hear.

Things are little better for the general prison population. The annual report from the Chief Inspector of Prisons complains of high healthcare staff vacancy rates and chronic recruitment and retention issues. In that context, Richard Garside, the director of the Centre for Crime and Justice Studies, concludes that the provision in Clause 35 to introduce a statutory target of 28 days for transfer from prison to hospital, while welcome, feels aspirational rather than practically implementable in the current system.

The broader crisis of staffing and resources and whether it will hinder the Bill, as we have seen in jails, is also mirrored outside the prison gates. Many briefings that we have all received for this Second Reading query whether the Bill will deliver its promises as a consequence of such problems.

I will now raise a related concern. I think that overstretched mental health services are not just a question of resources but rather a consequence of a recent cultural trend: the problematic medicalisation of more and more aspects of the human condition. Ever greater numbers of people are being encouraged—often by Government-backed policies—to view normal, if adverse or perhaps painful, life events through the prism of mental illness. As a consequence, a greater number of people now demand expert pharmacological or therapeutic intervention.

Over recent decades, this huge increase in classification in the psychological realm has moved the job of diagnosis far beyond the field of psychiatry. A veritable industry of counsellors, therapists and psychotherapeutic practitioners now label an ever-expanding set of behaviours as mental ill-health. As the number of labelled conditions has grown, those reporting that they suffer from such problems has risen exponentially. The stats bandied around are eye-watering. According to the psychologist Oliver James, a third of the adult population shows sign of “psychiatric morbidity”. The problems of worklessness and sick leave, which the Government are rightly tackling, seem dominated by those who have removed themselves from productive work because of mental health-related problems.

Student Minds reports that one in three students experiences clinical levels of psychological distress, but as it is now claimed that students might suffer PTSD if exposed to certain literary texts, it is difficult to assess the clinical authenticity of the so-called mental ill-health epidemic among the young.

The main thing is that the pathologising of ever more aspects of life has unintended consequences, some pertinent to the Bill. For example, we risk reducing the time and resources available to those who desperately need professional help if the system is clogged up with inappropriate referrals and arguably overdiagnosed conditions.

Finally, there is a danger of confusing public opinion if the true horrors and tragedy of serious psychotic illness are relativised and given the same mental health moniker as unpleasant but mundane psychological challenges.

Mental Health Bill [HL]

Baroness Fox of Buckley Excerpts

Committee stage
Monday 20th January 2025 Lords Chamber

[Baroness Bennett of Manor Castle (GP)]

My Lords, I will speak to my Amendments 67 and 86. I think that this is the right place—I apologise for my earlier confusion; I had a problem with the list.

I will start with Amendment 86 because it follows on from the very important contribution from the noble Lord, Lord Scriven. I should preface this by saying that I cannot claim that what I will say originates from me; it is based on the Law Society briefing, which many noble Lords will have received. I saw that nobody else had picked up this amendment, but I thought that it was so important that it should be picked up. As the explanatory statement says:

“The amendment would keep the safeguard of an automatic referral to the tribunal when a patient’s Community Treatment Order is revoked which results in them being detained in a mental health hospital”.


As the noble Lord, Lord Scriven, said, a range of views on CTOs has been expressed in these debates, but the general direction of travel is certainly not to remove safeguards and we should be keeping the safeguards that already apply. I will not claim great expertise on this, but it seemed to me that this is an important issue that we need to discuss in Committee.

Amendment 67 is somewhat different but really important. Later on, we will discuss very important issues, which I have signed amendments about, concerning minoritised communities being potentially overtargeted or subjected more to mental health provisions. This amendment picks up something that no one else has picked up, which is economic and social disparities relating to community treatment orders. I went looking for some statistics on CTOs in disadvantaged communities, but I was not able to split them out; perhaps the Minister has them. However, the charity Rethink Mental Illness talks about the burning injustice of how Mental Health Act detention rates are three and a half times higher in the most deprived areas of England compared with the least deprived. Looking at those figures, I can only see that CTOs must be something very similar to that.

We need to ask a question here, and we need the stats and that is why we should have the reporting. It is probably unclear whether we have a psychiatrisation of poverty, so that when people are living in conditions of poverty, that is seen as some form of mental illness in itself, or a discriminatory application of the law against people living in conditions of poverty. The third possibility is that poverty is making people ill. Either way, we should know about these facts. They should be regularly reported, and we should be able to examine them and check on them.

I was just looking at an issue that will be raised later about debt and mental health, on which I will point noble Lords who have not seen it to a really interesting POSTnote that the Parliamentary Office of Science and Technology produced on that subject last year. It suggests a two-way relationship between financial and mental well-being. People with mental health issues are three or more times more likely to have problem debt.

Some interesting recent research in a study published in Public Health indicates how social conditions are related to mental health. “Sandwich carers” in the UK —the 1.3 million people who have responsibility for caring for children and older parents—have experienced a significant decline in mental health.

These issues around social and economic disparities and the use of community treatment orders are embedded in the community, and it is crucial to see what is happening. Amendment 67 aims to ensure that we get regular reports relating to community treatment orders.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, I wanted to speak to this group because I made some harsh criticisms, on principle, of community treatment orders at Second Reading concerning their coercive and intrusive nature. Since then, perhaps similarly to the noble Lord, Lord Scriven, I have had cause to think again, not least after speaking to a number of working psychiatrists and taking on board the comments of the noble Baroness, Lady Parminter, at Second Reading, which really had an impact on me. It is quite unusual to change one’s mind in this place—maybe it is just me—so I wanted to note that.

I was reminded of this issue by practitioners—I was once one of those—when they said, “We worry about how many idealistic discussions about mental illness just do not take into account the reality of chronic mental illness”; I thought that was a fair reprimand. There are a group of people who are chronically symptomatic, perhaps some of them may never be well, and CTOs are a way to allow people to leave hospital who otherwise clinicians might worry would be too risky to release.

I have been thinking about this issue and in that sense was happy to see and support Amendment 44 in the name of the noble Lord, Lord Scriven, which sets out time limits. It is useful to think about probing time limits, renewal safeguards and so on, because one does not want automatic continuation and therefore indefinite CTOs on the books, which is what people are concerned about.

I would have been more enthusiastic about Amendment 66, put forward by the noble Lord, Lord Kamall, and the noble Earl, Lord Howe, which calls for a statutory review of CTO use, but the wording implies that CTOs are problematic per se. Perhaps we need a more open-ended review, because one of the reasons why CTOs are so contentious for so many people is their spiralling and increasing use, and we need to understand why that is.

One worry I have about the Bill in general, and not just this group of amendments, is that, because the drivers of the legislation are concerns about inappropriate hospital admissions and wanting to ensure that we have proportionate detention powers which are used only as a last resort, we need to be wary of demonising hospital care and recognise how much good can be done for mentally distressed patients in hospitals, particularly if they are given time and resources and the right kind of medical intervention. But, as with all hospital matters, that is not necessarily what is happening. Many psychiatric wards are under pressure to get people out into the community as soon as possible—in the sense not of them being well, but of freeing up hospital beds. One might wonder whether the CTOs are a mechanism for effectively turfing patients out before they are ready or well enough.

It also seems that CTOs are necessary when community care is under huge strain, because the idea of voluntarily accessing a wide variety of support in the community is a myth in today’s circumstances. All the briefings we have been sent draw attention to this. A range of groups and people have argued—and a number of noble Lords have said this today—that we need more resources, money and staff for appropriate care in the community to really work. That sounds reasonable, but I am concerned that this will miss the target. I want to reiterate the elephant in the room that I mentioned at Second Reading, which I have not changed my mind about: culturally, we are seeing the medicalisation of more and more problems of the human condition. This encourages ever greater numbers of people to view social, economic, educational and personal difficulties through the prism of mental health.

Mental Health Bill [HL]

Baroness Fox of Buckley Excerpts

Committee stage
Wednesday 22nd January 2025 Lords Chamber

[Lord Mawson (CB)]

I support Amendment 148 from the noble Lord, Lord Crisp. I have just arrived back from a three-day event with Professor Brian Cox in Northern Ireland, where we had been bringing together the NHS, schools, the business community and the public sector around a whole programme on innovation and how we think about the future with regard to these matters, taking the principles that we originally developed at the Bromley by Bow Centre in the East End of London, now nationally across the country.

If I look like I am in recovery, it is because I am—I have literally just landed trying to get back here. I apologise that I could not take part in the Second Reading, because being a working Peer, sometimes it is not very easy to fit all this into the diary. One does one’s best.

I am very aware of the questions that the noble Lord, Lord Crisp, is raising. Indeed, I tabled a number of Written Questions this week about this very matter. I support the amendments because we have a very serious problem out there. My GP colleagues are telling me, as the noble Lord, Lord Crisp, has said, that one in five adults in England is on antidepressants; it is one in four in Scotland. This is a really serious problem.

As a country, we need to return to a discussion and a conversation, as the Health Secretary—I hope, in the spring—prepares to help us rethink the future of the NHS. We need to return to the question that we asked 40 years ago in the East End of London, the fundamental question: “What is health?” What we see happening here is serious for hundreds of thousands of people and is driving a culture. We also need to start to worry about what is happening within the machinery of the NHS and the state, as it drives these sorts of cultures.

Finally, as I put down in one of my Written Questions, we need to be asking, practically, “How much is it costing the taxpayer to drive these kinds of cultures?” It is serious, but the problem is also an opportunity, if interest is raised in the work of those of us who have been doing stuff on the front line for many years with our GP colleagues. I see the noble Lord, Lord Clement-Jones, there: we have rebuilt a street together, with a £40 million school, a £60 million health centre, 600 homes and now a primary school, exploring this, in what when we began was a dysfunctional housing estate.

There is a real opportunity out there, but we now need to get real about antidepressants.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, I have some points I would like to probe in this group.

I especially welcome Amendment 95 and the proposed new clause:

“Ascertaining and learning from patients’ experiences of hospital treatment”.


The noble Earl, Lord Howe, made very powerful and moving points; we could really take those on board. I have some reservations, however: we live in a complaints culture. I am concerned that this important notion of learning from patients’ experiences does not become a way of stigmatising hospital staff and psychiatrists, with people queueing up to point the finger. There are many people I know who have experiences of hospital who will, at a particular time, tell you it was a terrible experience, and then, at another time, acknowledge that it saved their life. It depends on what phase they are in, in relation to their illness, in some ways—it is about their perspective. So I both welcome it and challenge it.

I am very keen, as we all are, that treatments are taken seriously, whether administered in hospital or in the community. As the noble Lord, Lord Crisp, and the noble Baroness, Lady Hollins, note in Amendment 148—for me, the most important amendment in this group—we need to be alert to when, for example, the use of psychiatric medication as a treatment creates a problem of dependency. We all know that this is a growing problem. We must consider that.

On the tenor of Amendments 50 and 51 from the noble Baronesses, Lady Tyler and Lady Bennett, on non-drug-based forms of medical treatment, I am less convinced by the emphasis here. I am worried about simply giving a wholly positive view of psychological and therapeutic treatments, because it perhaps misses some of the changes in today’s culture that lead to the overprescription of, for example, antidepressants.

When I was working in community mental health many moons ago, the fashion among progressives in the therapeutic community was often anti-psychiatry, anti-hospital and most definitely anti-pharmacological interventions, with a huge hostility to the pharmaceutical industry. I did not always go along with it, but that was the kind of mood. Peculiarly, I would argue that, today, it is therapeutic experts, counsellors and psychological practitioners who, by becoming diagnostically trigger-happy in labelling people as ill, are creating a huge demand both for third-party interventions, as I have discussed in previous speeches, and for treatment. That often leads to a clamouring, especially among younger people, for pills to help them to cope with the travails of life, and it has been egged on in some ways by therapeutic practitioners.

I had my attention drawn to this when, at the Academy of Ideas, I organised a debate on young people, mental health and those kinds of issues. The audience was largely young people, who said that the problem was that psychiatrists, GPs and doctors would not listen to them and would not believe that they were mentally ill. They demanded treatment and were quite aggressive. It was young people saying, “Where are my tablets?”, and I thought, “Oh, life’s changed slightly”. The psychiatrists in the room were trying to hold the line and gently suggest that maybe they were not ill, but that led to an even more hysterical reaction: “How dare you say I’m not ill?” They went on to explain how they had had a chat with their school counsellor, and they were sure they were ill, and they wanted the tablets.

If we can take a popular example that I appreciate might get me into the heart of an argument that I do not want to be in regarding the slippage between autism and mental illness, I am going to talk about ADHD. ADHD is the fashionable disorder of the day. Huge numbers of students and school pupils are demanding that their neurodevelopmental disorder is recognised and catered for. In my view, it is often diagnosed promiscuously and that is leading to huge demands that are detrimental to education and likely to make councils go bankrupt and schools collapse—but that is for a different debate and a different Bill. ADHD is also leading to a demand for tablets.

I go along with those who were warning about overdiagnosis. The Times reports that 278,000 people in England are on central nervous system stimulus to treat ADHD, and there was an 18% hike in prescriptions for ADHD drugs between April 2023 and March 2024. In the US, the figures are startling, and we should be wary of them, with 7 million American children who are said to have ADHD. As the New York Times has said, there is a danger that we are using stimulants to suppress

“all spontaneous behaviour in normal children”

by pumping them with Ritalin and other calming drugs and sedating normal children. In a broad sense, that is a worry.

Talking of treatments, I think the noble Lord, Lord Crisp, made the point that a social problem is being created of people feeling that if they are ill, they cannot go to work and of over-giving them drugs. All sorts of problems go along with that. Is it not tragic that so many people want to have these drugs, either for themselves or for their children, in order to feel that they can cope, when they are really not that ill or not ill at all, but they have the label? I am wary of inappropriate treatments, but perhaps the problem needs to be looked at differently, as stemming from inflated and expansive diagnostic criteria often deployed from within the therapeutic community rather than psychiatry.

We should not be naive in thinking that non-drug-based therapeutic interventions are virtuous per se. Counselling, for example, has extended its reach into British society so much that it is now a rare family that has no experience of the phenomenon. I am sure that we all know that going to a therapist or counsellor is, to say the least, a mixed bag when, ironically, they end up saying that you need to have third-party intervention or medical intervention. It is bad for the nation’s health.

--- Later in debate ---

[Baroness Fox of Buckley (Non-Afl)]

I want to ask the noble Baroness a question. I agree that this Mental Health Bill should be confined to and is about the people who are very poorly and could be in danger of being detained—I understand that. However, all the time when we have these discussions, we are talking about a problem with a lack of resources. In the noble Baroness’s experience, is the broader mental health crisis taking away resources and focus, not in this Bill but in society, from giving that acute mental health care the resources that it needs—because it is being spread far too thinly across ever greater numbers?

[Baroness Murphy (CB)]

Yes, I would say that indeed it was. That year when they gave an extra £400,000 to spreading psychotherapy around was the same time when we were having incredible crises in acute hospital services, and I thought that it was not justified. But the mental health crisis that we have in this country is the same one that they were complaining about in 1860, 1870 and 1880; every generation believes that it is worse off than the generation before, but there is not much evidence that it is.

Mental Health Bill [HL]

Baroness Fox of Buckley Excerpts

Committee stage
Monday 27th January 2025 Lords Chamber

[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 ---

[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.

[Lord Meston (CB)]

My Lords, I briefly want to support Amendment 151 in the context of the delays experienced by CAMHS—delays in obtaining appointments and assessments, and in getting treatment. When I last had to look at this, only recently, those delays were still very serious. They are distressing for the children concerned and for their parents. They are also frustrating for local authorities, social workers and the courts, which need to make informed decisions but are unable to do so because they are still waiting to understand what CAMHS have to say about a particular child’s problems.

Mental Health Bill [HL]

Baroness Fox of Buckley Excerpts

Committee stage
Monday 24th February 2025 Lords Chamber

[Baroness Neuberger (CB)]

My Lords, I will speak very briefly in support of Amendments 163 and 164, to which I have added my name, and particularly about the length of time, the five years.

We first started talking about the reforms to the mental health legislation eight years ago, when we set up the review of the legislation under Sir Simon Wessely, and I was the vice-chair. It reported in 2018—seven years ago—and it was not even a very radical rethink of our mental health legislation. Yes, it will make a lot of difference to a lot of people—service users are very keen for this to come about, and they certainly do not want to wait longer than five years to see all the measures come into force—but this is relatively gentle stuff. At some stage we will need a much more radical rethink of our mental health legislation. Five years is quite a long time, so I rather hope the Minister can give us some comfort by saying that most of it will be done in two years, or perhaps three years at the outside.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, first, I support Amendment 130 in the name of the noble Lord, Lord Scriven. I have been concerned, as we have discussed this Bill, that costs are likely to spiral. I am not objecting to that, but it seems to be the elephant in the room. Unless we know, the Bill will become a white elephant because people will just say that we cannot afford to do it. It is far better to have transparency, as has been argued.

Secondly, I oppose Amendment 153. For a number of reasons, I do not think we should prohibit for-profit entities being involved in this endeavour. The suggestion is that if we remove the profit motive, all will be well. A word of caution: not-for-profit organisations are not necessarily the most efficient, virtuous organisations, as we might imagine. In the charitable sector there are some worrying trends of money being spent, rather self-indulgently, on staffing and on all manner of extraneous and sometimes politicised endeavours.

We have seen the emergence of EDI—equality, diversity and inclusion—policies, which the Health Minister, Wes Streeting, has worried about happening in the state sector, and we have seen them become absolutely rampant in the charitable and not-for-profit sector. I want us to concentrate on the people the Bill is designed to help and therefore not to have our own political idea that only the state can deliver well—I just do not believe that is true.

For example, I have done work in prisons over a period of time—that also relates to the Bill—and have worked in both private and state-run prisons. Some private prisons are awful and some state-run prisons are worse—and, by the way, I have worked in some brilliant state-run prisons and some brilliant privately run prisons. We should judge on the basis of the quality of the care or the service that they provide, not some prior presumption that because they make profit they might be useless, somehow evil or not attending to their core mission.

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[Baroness Browning (Con)]

My Lords, I too was pleased to add my name to Amendments 155 and 156 in the name of the noble Baroness, Lady Hollins. She has already spoken on this subject, and it would be remiss of me not to say that the title of the report she mentioned, My Heart Breaks—which is of course in her name and authorship—was chosen for a purpose. This is a heartbreaking situation, and on the piece of paper I am holding in my hand, headed GOV.UK, it says: My Heart Breaks—Solitary Confinement in Hospital Has No Therapeutic Benefit for People With a Learning Disability and Autistic People.

As we have heard, it is not just that it is not therapeutic; it is actually harmful. On the terminology, other speakers have already spelled out why they have dumbed down the real raw facts of the language that they use to describe this type of incarceration—for that is what it is. It reminds one of prisons. Look at the legal structures needed to put somebody into a prison, yet people who are ill are treated in the same way as prisoners.

I remember visiting a school for autistic children many years ago. It had a single room where they took children who were having a meltdown. It was a padded room, and they felt that was the appropriate treatment for children. We know, from the many debates in this House about people who have been held for extended periods in mental health hospitals, the damage it does and the difficulties when these practices are in place.

Ironically, this does not happen everywhere. You have to ask why it happens in some institutions and not in others. There is an answer to that. It is not because of a different profile of patients in these two different types of settings but because in some places they understand the problem and have sufficient training and resources. Training of personnel, particularly senior personnel, is key. If the person in charge says, “This is what we are going to do”, very few people in the structure below them are going to challenge it, so that is what they do and it becomes the norm.

Fifteen months ago the noble Baroness, Lady Hollins, produced this report, which now bears government approval and GOV.UK and the Department of Health and Social Care on it. It is now really time for the Government to adopt the amendments from the noble Baroness, Lady Hollins, and her recommendations. It is a wealth of experience that we can only admire, and I urge the Minister to please accept these recommendations. They come from the very highest level. We are very lucky in this House to have the expertise of my dear friend, the noble Baroness, Lady Hollins.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, I will speak very briefly and on a slightly related topic. I want to talk about a different group of people who are in long-term segregation who are not sectioned and often do not get mentioned—prisoners. Long-term segregation is used when very mentally ill people in prison are not transferred to hospital and nobody knows what to do with them. They are put into isolation and left there, psychotic, delusional and forgotten—dumped, in effect.

The noble Baroness, Lady Browning, alluded to prisons, but even prisoners should not be treated like prisoners sometimes. The confusion and conflation of punishment and treatment outside prison is no less shocking when it is inside prison. You are not meant to punish somebody doubly because they are in prison and happen to get ill.

The Chief Inspector of Prisons, Charlie Taylor, has made the point that the segregation units are completely unsuitable for people who are severely unwell. They are also a significant drain on the hard-pressed staff, because very often the restraints are of people literally going out of their mind. They are not getting any medical intervention at all. According to the chief inspector, it requires multiple officers to unlock the cells even just to deliver meals.

Is it possible for the Minister to give any thoughts on that? Also, in a way, this is an appeal to the noble Baroness, Lady Hollins—if she takes this amendment forward—to bring that into the situation, even though I know I am slightly squeezing it in because I have Amendment 160A on reviewing prisons.

On Amendment 146 and the use of force, I absolutely agree with the mover of the amendment in relation to the need to keep records. That is obvious. I suppose the nightmare for us all is the misuse of force. It is horrifying—the stuff of nightmares—when people are ill.

I do not want to be naive. I know that when people are very ill and very psychotic, sometimes appropriate force is necessary; I just think it needs to be recorded. When I say force, I obviously do not mean violence or anything not within the realms of professional intervention. Sometimes I think we forget how ill people can be and how violent and how difficult it is for the people who work with them. We should record every instance of the use of force but be wary of demonising or damning every use of it, because it is not quite as simple as that.

[Baroness Watkins of Tavistock (CB)]

My Lords, I support all three amendments in this group but make the point that a lot of NHS care is now commissioned into the independent and charitable sectors. It is vital that records are kept in any care setting that is paid for by the NHS, not just by NHS facilities. I also believe that recording will reduce these kinds of behaviours because it will make people think much more carefully, particularly in long-term segregation. As you get to 10 days, people will be thinking, “How can we change the care we are delivering to avoid that 15-day reporting sanction?”. It really is imperative that we do this. We are treating some of the people who have the greatest needs in our society really badly.

Mental Health Bill [HL]

Baroness Fox of Buckley Excerpts

Committee stage
Monday 24th February 2025 Lords Chamber

Moved by

[Baroness Fox of Buckley]

160A: After Clause 50, insert the following new Clause—
“Review: impact of this Act on the prison estate(1) Within 12 months of the day on which this Act is passed, the Secretary of State must publish a review of the impact of provisions in this Act related to the treatment and care of mentally disordered persons on—(a) under 18s in youth offender institutions,(b) IPP prisoners,(c) female prisoners, and(d) any other such persons they deem appropriate.(2) In the review, the Secretary of State must assess whether, in their view, the Act provides adequate support for ongoing treatment and care of mentally disordered persons in a prison setting.”Member’s explanatory statement
This amendment requires the Secretary of State to publish a review of the impact of the provisions of the Act on prisons and to assess whether the Act provides for adequate support for ongoing treatment and care in these settings.

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[Baroness Fox of Buckley (Non-Afl)]

My Lords, after all that excitement, I fear I may be a bit of an anticlimax, but I will carry on regardless—and let people walk out. My Amendment 160A calls for a review of the impact of the Act on the prison estate and the ongoing treatment and care of mentally disordered people in a prison setting a year after the Act passes. We have all welcomed the Bill’s commitment to ending the use of prison cells as so-called places of safety, but as some of us noted in the debate on an earlier group, the promise of, for example, a transfer to hospital for prisoners facing acute crises within 28 days is widely viewed by criminal justice stakeholders as unlikely to happen. We need to review whether such cynicism is merited, because the prison reform aspects of the Bill are not minor. They should not be treated as Cinderella clauses: they are, to my mind, crucial.

We cannot pass this Act and leave prisoners who ought to be in hospital beds abandoned in squalid conditions in jails. Additionally, it is not fair to prison staff because, to quote Andrew Neilson from the Howard League:

“Our overcrowded prison system that has been asked to do much, with too little, for too long, is ill-equipped to help people who require intensive support for their mental health”.


I recently visited Five Wells prison in Wellingborough with my Academy of Ideas hat on. The new leadership team at Five Wells is doing some fantastic work on purposeful rehabilitation activities, and we hope to do a joint project of Debating Matters Beyond Bars with it there. I chatted more generally to the team members, who have worked in a variety of prisons over the years, and they all noted that the time and emotional strain on staff when dealing with psychotic and very poorly prisoners—they gave gory examples of prisoners eating their own faeces or making very bloody attempts at self-harm, et cetera—have been totally demoralising for officers. It may have been one of the reasons for the use of the segregation units I talked about earlier. But these things have also had a destabilising and frightening impact on other prisoners. Sharing space with those with paranoid delusions and who present a violent threat to themselves and others is no joke; it makes prison difficult for everyone. So it is crucial that we get this right in the context of an overstretched prison crisis, and a specific view would focus minds.

I also think that we cannot let the Bill pass into law without acknowledging that there is considerable public disquiet about the relationship between criminal justice and mental health care. What do we do about the detention of those convicted of serious crimes due to diminished responsibility, where professionals see secure hospitals as more appropriate than prison? I am sure we can all recognise that, for many victims and their families, this hospital option can feel like an injustice.

I am, of course, thinking of the high-profile and controversial case of Valdo Calocane. According to the recently published independent investigation, it was repeated failures to treat Calocane’s paranoid schizophrenia and violent outbursts that left him free to kill Barnaby Webber, Grace O’Malley-Kumar and Ian Coates in June 2023. More pertinently in relation to the Bill, the families of these tragic victims fear that Calocane may have been spared prison due to incomplete evidence presented in court, especially about his mental capacity. This is now exposed in the 302-page investigative report, and the families have concluded:

“This was a man who actively avoided his medication and treatment, knowing that when he didn't take his medication he would become paranoid and violent”.


This is interesting for our deliberations, because we now know that the doctors responsible for Calocane’s case repeatedly ignored the nurses treating him in the community, who begged for him to be put on a CTO to ensure that he took long-acting anti-psychotic drugs. Why were they ignored? It seems that the clinical team at Nottinghamshire Healthcare Foundation Trust made decisions “influenced” by the draft Mental Health Bill 2022. Those medics were very conscious of legislation down the line that seeks to raise the threshold of detention and reduce the use of CTOs, and of the call for a reduction of compulsion in medicating patients in the community. Then there is the issue of patient rights, in Calocane’s reluctance to take medication because he did not like needles. Staff were, we are told, acutely aware of the Bill highlighting the “disproportionate” use of restrictive practices on black African or black Caribbean patients—and so on and so forth.

--- Later in debate ---

Addressing the mental health needs of offenders as a critical element of tackling the root causes of offending behaviour, which is of the utmost importance to this Government. I hope this reassures the noble Baroness that we agree on the importance of ensuring that those with severe mental health conditions receive the necessary support and that we are committed to continuing to review and improve this area in future. It is for these reasons that I urge her to withdraw her amendment.

[Baroness Fox of Buckley (Non-Afl)]

Briefly, I say thank you very much to the Minister, the noble Lord, Lord Timpson, who obviously has an intimate and empathetic relationship with the prison estate and the issues that I was raising. I appreciate that he and I share very similar concerns. The difficulty is—I do not think it is just the hour—that the Bill says it will resolve things in relation to prisons but, actually, the discussion around prisons has been rather neglected. I understand why.

The reason I mentioned Mr Calocane is that a lot of the issues in the community and a lot of the public debate about mental health concern the notion of people being ill, wandering around, not being safe and so on and so forth, and I could not think of another way of raising that here. That then affects the prison estate, because people phone the police and then people get taken to prison—or they have been let out of prison when they are mentally ill, and so on and so forth. That is one thing. It requires much greater scrutiny and debate, not just through this Bill but in general in Parliament: that is the first thing. I also think that we have not got public opinion our side on this, in many ways. People are not sure why people are sent to prison in some instances and to hospital in another. I do not expect the Minister to reply, but I think that needs to be acknowledged.

Secondly, I note that, even though I used the example of Five Wells prison, if all the awful things were not happening there, it was based on prison officers’ experiences in many places. I do not want in any way to put the prison into any difficulties, because it is actually doing a very good job in very difficult circumstances. I will just say that I think that, on paper, this Bill will make a small impact, but I think there is much further that it could go. I am glad to hear that different groups will be taken seriously. I withdraw the amendment, but I think we have a long way to go and I will keep pursuing this. I thank noble Lords who spoke in support; I really appreciate that.

Amendment 160A withdrawn.

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[Baroness Tyler of Enfield (LD)]

My Lords, I rise quickly to say that I am very sympathetic to the aims behind these two amendments. They have been set out very powerfully and comprehensively by the noble Earl, Lord Howe. I feel, particularly, that an obligation to publish a report of an investigation of the type we have just heard about is absolutely essential if we are to avoid a repetition of these terrible events. There must be a way of learning lessons from this, and transparency and publication are an important part of that.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, I was pleased to see these amendments as well. The noble Earl, Lord Howe, explained why they are important. He has conceded—I tried to imply the same in my own amendment—that it is not necessarily clear how best to raise these issues, but that we need to. If we are seen by the public discussing a mental health Bill, going through the whole thing and refusing to acknowledge one of the big controversies of recent times, which was a mental health issue, it will discredit the Bill when it becomes an Act.

In relation to the reluctance of the NHS trust to publish its investigation and the use of patient confidentiality, I note that the families of the victims saw this very much as an excuse and were very angry about that. It does not help us to have a discussion with the public about mental illness because it then seems as though murder was committed but, somehow, mental illness was used as an excuse. We have all heard that argument being used; that is why I referred to the fact that there was some dispute about whether Calocane should be sent to prison or to hospital. The more openness that we can give this, the less stigma and confusion there will be. We need to have this debate out in the open.

Finally, I have a question on the judge-led inquiry and what we now know from the investigation by the trust. How will that impact this Bill? How, practically, will we be able to incorporate what we have learned from that into our discussion on a whole new piece of legislation on mental health? It would seem that we need to be able to take on board some of the recommendations of the inquiry and what we now know from the investigation by the trust.

[Baroness Merron (Lab)]

My Lords, I thank the noble Earl, Lord Howe, for tabling Amendments 160BA and 160BB, supported by the noble Lord, Lord Kamall, and spoken to by the noble Baronesses, Lady Tyler and Lady Fox.

I say at the outset that I understand the deep concerns raised today by noble Lords. I would like to take this opportunity to express my sincere condolences, and I am sure those of the whole of your Lordships’ House, to the families of Grace O’Malley-Kumar, Barnaby Webber and Ian Coates. The Secretary of State and I have met the bereaved families following these horrific killings, and, rightly, important actions have been taken, which the noble Earl, Lord Howe, asked about. Indeed, we have to look at what improvements must be made, both at the trust and across the country.

To take this further, NHS England and the Nottinghamshire Healthcare NHS Foundation Trust have accepted all of the recommendations made following the Section 48 CQC review into this incident, and action has started on implementation. The recently published independent investigation into the care and treatment provided to Valdo Calocane makes a series of recommendations, which NHS England and the Nottinghamshire Healthcare NHS Foundation Trust have accepted. I reiterate that the Government expect to see swift action to ensure that the recommendations are implemented as soon as possible. As the Prime Minister has confirmed, and as the noble Earl, Lord Howe, acknowledged, there will be a judge-led, statutory public inquiry into this tragic incident.

I now turn specifically to the amendments, and first to Amendment 160BA. We recognise the importance of transparency when there are concerns around a patient’s care, to enable a full understanding of what went wrong and how learning can be applied as a result. The courts already have legal powers to request, and where appropriate compel, disclosure of relevant reports, ensuring judicial access to relevant information. In criminal and civil proceedings, courts can make orders that particular information be provided, or issue witness summonses, while coroners can obtain documents as part of an inquest. There is no clear evidence that courts face systemic barriers in accessing necessary information.

There are also existing mechanisms to provide robust oversight and transparency. NHS England’s patient safety incident response framework sets out clear guidelines for responding to serious incidents involving patients who are detained under the Mental Health Act. Additional scrutiny is provided through investigations by the Health Services Safety Investigations Body and oversight from the CQC.

If information is not disclosed, interested parties already have mechanisms to access information, including judicial review, freedom of information requests and the coronial process for deaths in detention. While courts have the powers set out in the amendment, we absolutely recognise the importance of openness in mental health services, which is why officials are working with NHS England to ensure that information from investigations is as transparent as possible—something that all noble Lords have rightly referred to.

Mental Health Bill [HL]

Baroness Fox of Buckley Excerpts

Report stage
Monday 31st March 2025 Lords Chamber

[Lord Bradley (Lab)]

My Lords, I declare my interests as listed in the register.

In Committee, I moved an amendment that would require a specified accountable person to be appointed by the relevant referring body to ensure that the specified 28-day transfer period is met. This proposal was based on the fact that many agencies are involved in arranging prison transfers. From my experiences in helping to develop services across health and justice, I believe there could be significant merit in creating a single role: a dedicated official whose primary function would be to ensure efficient transfers, with the ability and power to liaise and intervene with the various agencies at the most senior level where necessary.

As I said in that debate, the amendment would clarify and enhance accountability and transparency, and

“support the desire expressed in the impact assessment”

of the Bill to increase

“‘accountability for all agencies involved in the transfer process to meet’ … the deadline”.

It is important to note again that this is 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’”.—[Official Report, 27/1/25; col. 61.]

At the conclusion to that debate, first, the noble Lord, Lord Kamall, from the Opposition Front Bench, commented that my amendment

“again, speaks to the point of implementation”

of provisions in the Bill, and said that this

“could be a sensible way of holding providers to account and working with them to address the shortcomings in patient transfers”.—[Official Report, 27/1/25; col. 66.]

Secondly, and most importantly, the Minister, my noble friend Lord Timpson, helpfully reminded the House that the previous Government had run a public consultation seeking views on the effective way to establish this role, but no consensus was reached. Further, a cross-agency working group was established to scope out the role, and that work

“continues between health and justice partners”

on this issue. He suggested that a non-statutory approach

“will ensure that the interests of patients are considered while providing the flexibility required, given the complexity of the process”.—[Official Report, 27/1/25; cols. 67-68.]

Very helpfully again, the Minister offered to meet to discuss this further and for that to be undertaken before Report. I am very pleased that such discussions have taken place, and thank not only the Minister but the excellent officials in both the Ministry of Justice and NHS England for their very constructive engagement with me.

I still strongly believe that we need effective oversight of the transfer process, hence I tabled Amendment 38, which proposes that either an accountable person “or body”—a slight extension to my original amendment—is established for the purpose and, of course, to ensure accountability and transparency to Parliament on this matter. I hope the Minister will now support this proposition. I look forward to his response at the end of this short debate and will listen carefully to it. I beg to move.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, in Committee, a number of us stressed the importance of those sections of the Bill relating to its application for prisoners suffering mental disorder. I continue to push to ensure that the parts of the Bill that relate to the responsibilities of the MoJ in relation to the Department of Health and Social Care are not neglected once the Act becomes law.

In Committee, I focused on calling for a government review of the impact of the Bill on prisoners, but, from listening to the thoughtful response from the noble Lord, Lord Timpson, I saw that this could become yet another bureaucratic report. I therefore commend Amendment 38 from the noble Lord, Lord Bradley, as an elegant way of ensuring that the crucial provision of a transfer to hospital within 28 days is more than an “if only” paper aspiration.

My Amendment 40, which I am delighted is supported by the noble Baroness, Lady Bennett of Manor Castle, is also a practical proposal. It is designed to tackle problems that directly pertain to the Bill, broadly because, regardless of this legislation, the reality is that there will continue to be large numbers of prisoners suffering mental disorders who are incarcerated within the prison estate rather than in secure hospitals. The question then is what happens to their mental health care when they are released. If this aspect is neglected, these ex-prisoners could well become increasingly unwell and deteriorate, and therefore be in need of future detention.

It would be a real mistake to neglect any policy or practice associated with this Bill that fails to address the need for bespoke, ongoing support in the community, in which ex-prisoners’ mental health is not allowed to fall further, creating new risks to both them and the public. This is a real risk. Estimates from a 2023 report from the Centre for Mental Health, based on a survey of 75% of prisons and young offenders’ institutions in England, found that one in seven prisoners receive mental health support while in custody—the figure is one in four among women. However, continuity of that care collapses after release. Research led by the University of Manchester recently found that, of 53 prisoners who had been in touch with in-house services due to severe and enduring mental health conditions, only four were in touch with community health services six months after release.

It is perhaps understandable why this happens. When leaving prison, both the authorities and prisoners may focus on practical challenges, such as lack of housing and how to earn money and a living, and therefore mental health support can and does slip down the priority list. It is also the case that leaving prison can present a shock to the system, and that affects this. Prisoners will be leaving a structured environment, focused on routine, and, in many instances, returning to more disorganised and chaotic conditions. Freedom may mean an arbitrary end to an effective course of treatment, someone having waited perhaps months or even years to access services, such as therapy or specialised groups, in which they have started to open up about traumatic experiences—all in-prison services. Suddenly, on release, there is an abrupt end to such support. Targeted interventions, prescribing regimes and the access to medication inside are no longer guaranteed on the outside.

I understand that ensuring continuity of care can be incredibly difficult. People leaving prison often have multiple and complex needs, and can be wary of accessing care in the community because of a lack of trust in state institutions that means that they are less likely to proactively seek out help. Ex-prisoners report that they fear that disclosing mental health challenges to, for example, probation staff will draw attention to their vulnerabilities. Then there is the dread of recall—an especially acute fear for IPP prisoners: a fear of being sent back to prison if they appear too ill to cope, or a dread of that other detention mechanism, sectioning.

All that this amendment seeks is to ensure a smooth handover between prisoners and community services. Without such ministerial reassurance, I fear that this will undermine core parts of the Bill unless it is taken into account. The stock reply to such concerns is that prison mental health services send on information to prisoners’ GPs, but in the real world this is often nonsense. Prisoners often do not have a fixed address on release, so they are discharged with just a medical letter. Prison nurses explain that they do not know where their patient will be released to, beyond a hostel somewhere, making it impossible to connect that person to even primary care. Prison-led medical staff complain that often they are not informed of the impending release until very shortly beforehand—sometimes a week or days—and this is especially acute in relation to the present early release scheme. There is not enough time to set up appropriate community provision, to communicate with services or even to conduct proper assessments of individual patients before their release. Clinical needs are therefore deprioritised, and prisoners fall through the net of statutory services.

What is needed, and what this amendment envisages, is that a relevant detention authority is responsible for discharge packages which will, for example, register prisoners with GP services in the precise area a person is discharged to, and liaise with relevant third-party organisations and community provision to make arrangements. Prisons and health authorities would work together to prevent deteriorating mental health and the potential for behaviour on the outside that would mean yet more contact with the criminal justice system for the ex-prisoner and, possibly, emergency intervention and detention.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I support Amendment 40, tabled by the noble Baroness, Lady Fox, and have added my name to it—probably not a combination that you will see very often. This amendment, as the noble Baroness set out with practical, clear evidence, makes such a lot of sense that I had to back it.

My particular interest when it comes to prison policy is women in prison. More and more shocking figures are emerging all the time about what is happening in our women’s prisons. A third of women in prison are now self-harming, which is a 29% increase in the last quarter, and 82% of women in prison report mental health problems. As the noble Baroness said, one in four women in prison are receiving help from mental health services. That is not to say that there are not enormous issues around male jails as well—the figure for male jails is one in seven—but I want to take a moment to paint a picture.

Six in 10 female prisoners are serving sentences of less than six months. Their life is torn apart and they are put into prison, where maybe they start to get help from the mental health services. Here are some other figures: seven in 10 women in prison report being victims of domestic violence; 53% report that they were victims of child abuse. We have a huge and often acute need for mental health services here, yet, as the noble Baroness set out, these women are thrown out, virtually on to the street, and the chances of continuing care and support being there are utterly unrealistic.

I suspect the Minister will say that the Government are trying to improve the situation. I respect and understand that. None the less, this is a practical, sensible measure that it would be common sense for the Government to take on board.

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[The Minister of State, Ministry of Justice (Lord Timpson) (Lab)]

I am grateful to my noble friend Lord Bradley for bringing this discussion before the House today and his commitment to improving outcomes for patients since the publication in 2009 of the Bradley Report, which highlighted the need to ensure that transfers between prison and secure hospital take place in a timely manner. I also thank him for his kind words about my superb team in the Ministry of Justice.

The Government are committed to addressing the unnecessary delays that some patients experience, which can cause significant distress to these individuals, their families and those charged with their care. Transparency and accountability, as the noble Lord, Lord Davies of Brixton, and the noble Baroness, Lady Tyler, expressed clearly, are essential to the successful implementation of this reform and to reducing delays more broadly. I thank my noble friend Lord Bradley for the constructive conversations with my officials since Committee to ensure we get this oversight mechanism right.

I am pleased to share that this Government have recently established a health and justice strategic advisory group, which will bring together key partners with responsibility for the various parts of the transfer process. This group will be chaired by a national clinical director, who will report regularly to Ministers and be responsible for agreeing a joint work plan to support implementation of the statutory time limit, identifying solutions to common barriers to timely transfers and holding partners to account. I am confident that this group will provide effective oversight by bringing together operational leaders across health and justice with the levers necessary to effect change, while inviting challenge from critical friends such as the Care Quality Commission and His Majesty’s Inspectorate of Prisons to ensure external scrutiny. I will continue to work closely with my noble friend Lady Merron to ensure that the long-term future of the strategic advisory group remains a priority.

As my noble friend announced earlier, the Government have committed to providing an annual report to Parliament on the implementation of the Mental Health Act reforms. Through this reporting mechanism, I will update Parliament on the implementation of the statutory time limit and on the strategic advisory group, and provide data on transfer timelines when available for publication. I hope this reassures my noble friend of this Government’s commitment to improving timely access to treatment. I urge him to withdraw his amendment.

Amendment 40 tabled by the noble Baroness, Lady Fox, and supported by the noble Baroness, Lady Bennett of Manor Castle, would ensure that prisoners released into the community who have previously been treated for a mental disorder can continue to receive access to treatment in the community. Section 117 of the Mental Health Act already places a duty on health and social care services to provide aftercare to patients under specific criminal justice sections of the Act who are released from hospital into prison or into the community. These services aim to reduce the risk of a deterioration of the patient’s mental condition and, accordingly, the risk of them requiring admission to hospital again for treatment.

The noble Baroness, Lady Bennett, is right that our women’s prisons have many women who are mentally unwell. That is why we have set up the Women’s Justice Board—to reduce the number of women in prison and to help divert many women away from custody in the first place.

The noble Baroness, Lady Fox, will be pleased to know that, in addition to the Section 117 aftercare that is available to those detained under the Mental Health Act, all prisoners who have engaged in any form of treatment while in prison—regardless of whether they have been detained under the Mental Health Act —have access to services in the community when they are released.

To strengthen the links between substance misuse and health services in prisons and in the community, and to support access to treatment, we have recruited 57 health and justice partnership co-ordinators and managers across all probation regions in England and Wales. NHS England’s RECONNECT, a care after custody service, supports prison leavers with vulnerabilities including mental health needs to engage with the right health services in the community through referrals and peer support. The noble Lord, Lord Kamall, is right: through-the-gate continuity is crucial. The successful pathway is how we reduce reoffending and help people who are unwell.

I hope this reassures the noble Baroness that there is already sufficient provision in the Act to ensure that prisoners who have previously been treated for a mental disorder can continue to receive access to treatment in the community. I urge her not to move the amendment.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, I do not doubt in any way that prisoners can access that community care; the problem is that they are not accessing it. The assurances about new schemes are positive, but the idea was to make this more than just an abstract wish list and make sure that something practical happens. If that is what the new scheme—although it does not exist yet—will do, that is reassuring, but it is certainly not what is happening now.

Mental Health Bill [HL]

Baroness Fox of Buckley Excerpts

Report stage
Wednesday 2nd April 2025 Lords Chamber

[Baroness Bennett of Manor Castle (GP)]

My Lords, it is a pleasure to follow the noble Baroness, Lady Tyler. I have attached my name to the noble Baroness’s Amendment 49. As the noble Baroness said, like Amendment 48 it addresses one of the primary reasons for reviewing the Mental Health Act in the first place. Black people are over 3.5 times more likely to be detained under the Mental Health Act than white people, and over seven times more likely to be placed on a community treatment order. Their experiences and outcomes are worse. All of those are facts. As the noble Baroness, Lady Tyler, said, the Bill somehow does not seem to be addressing that. We are taking an overall systemic view but not addressing the issues of a particular population. The reason I chose to sign Amendment 49—we are going to come shortly to the amendment in the name of the noble Lord, Lord Stevens, looking at the resources being put into the Mental Health Act—is that this is another way of putting resources into what everyone agrees is a crucial issue. This is a different way of allocating resources.

The noble Baroness, Lady Tyler, has made the case that PCREF is not the same thing. The Care Quality Commission does not have the same kind of situation. We are talking about people at a local trust level here; that is where the responsible person would be. As the noble Baroness said, if there is already someone, because of local arrangements, fulfilling this role, they can simply adopt this along the way. It does not have to be any kind of duplication. I note that the campaign group Mind very strongly backs this amendment. It delivers where we started from on this whole Bill.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, I will speak to Amendment 61, which calls for a review into the causes and consequences of the huge spike of diagnoses of mental disorders. It should also investigate the impact of this on the availability of services that we envisage treating people with a mental disorder that this Bill seeks to help.

If, in our best efforts to provide alternatives to detention for the severely ill, we hope to ensure that adequate care in community settings exists, we must look at the phenomenon that threatens to squeeze out those who most need access to such services. Implicit to this endeavour is to ask if, inadvertently, some aspects of policy set in train a self-fulfilling prophecy. Rebranding any deviation from the norm, troublesome behaviour, anxiety or even, according to the Government’s curriculum review, GCSE exam stress, under the therapeutic language of mental health has consequences. As Tony Blair has noted recently:

“you’ve got to be careful of encouraging people to think they’ve got some sort of condition other than simply confronting the challenges of life”.

Yet the young especially are prone to internalising the narrative of medicalised explanation and adopt an identity of mental fragility and illness. This can create a cohort of citizens demanding official diagnoses, NHS intervention and treatment.

This week, the media has featured the new book by Dr Alastair Santhouse, a neuropsychiatrist from Maudsley Hospital. In the book No More Normal: Mental Health in an Age of Over-Diagnosis, Dr Santhouse argues that it has become crucial to reassess what constitutes mental illness:

“so that we can decide who needs to be treated with the limited resources available, and who can be helped in other ways”.

He worries the NHS has

“buckled under the tsunami of referrals”.

Other state services are straining to the point of dysfunction as well. Despite the fact that the number of children with education, health and care plans has more than doubled in less than 10 years, parents are still desperately complaining about waiting for years for autism and other assessments. In other words, the demand is just galloping.

All of this is leading to at least 18 councils being at risk of insolvency, according to the Guardian on Monday. The present row over PIPs and the welfare system collapsing under the costs of ever greater numbers claiming disability payments for mental disorders is now a major political issue. I have been partly inspired to table this amendment by the Health Secretary Wes Streeting’s concern about overdiagnosis of working-age adults leading them to be “written off”, as he said. It is especially tragic that this is happening overwhelmingly among young people.

My concern, and the point of this amendment, is that this can skew NHS provision. A Savanta poll of 1,001 GPs for the Centre for Social Justice’s report Change the Prescription reported that four in five, 84%, of GPs believe that the ups and downs of normal life are now wrongly being redefined by society as mental disorders. Of those GPs, 83% now believe that anti-depressants are too easily prescribed to patients. But the GPs are under so much pressure from patients demanding treatment that they prescribe them. Similarly, in 2013 and 2014 just 1,800 adults were prescribed drugs for ADHD, but last year 150,000 adults were prescribed with ADHD medication. Waiting lists keep growing and lots of anger continues.

When I last spoke on this topic in the Mental Health Bill debate, the media picked up on it and I was inundated with emails, largely from people furious with me for challenging overdiagnosis; I had a tsunami of hate mail. There was even a formal complaint sent to the standards committee of the House. People said, and I understood it, “How can you say there is an issue with overdiagnosis when I can’t get a referral for myself” or “for my child” and so on. It is true that a GP cannot formally diagnose ADHD as it requires specialist assessments. The average waiting list for an ADHD referral on the NHS is now three years. This lack of formal diagnosis is not necessarily stopping service provision becoming overwhelmed and distorted, and I think this mood will have a very damaging impact on what we want this Bill to do.

I will finish with an apocryphal tale from the University of Oxford’s disability report from 2022-23. It reveals that the university has, under pressure from students, agreed to

“accept a wider range of disability evidence”

as a key to giving 25% more time in exams and the use of computers in exams. The university’s explanation is telling. It talks of

“a wider context of extensive and ever-growing waiting times for ADHD and autism diagnostic assessments”,

so it aims to reduce “administrative burdens and barriers” for disabled students.

--- Later in debate ---

[Baroness Browning (Con)]

Before the noble Baroness sits down, she mentioned autism several times, but the whole purpose of the Bill is to remove autism and learning disability from mental health, where it previously was. In fact, I served on the Bill Committee, as did others in the Chamber, in 2005-06, when I was really opposed to autism being added to the 1983 Act. But it was added, and now it is being taken out, I am very pleased to say.

I hope that the noble Baroness will accept that there is a piece of legislation about this on the statute book: the Autism Act 2009, which is being reviewed by the House at the moment. Autism is not some fad, something that people just make up, or something temporary; it is a lifelong neurological condition. I raise the failure to provide the right services for people with autism who are in that part of the spectrum where they need support. Not everybody does: it is a spectrum, and I quite agree that there are people on the spectrum who cope quite well with life, knowing that they have autism and not needing that sort of support. We have discussed that support a lot in the course of this particular Bill, and if you do not provide it where it is needed—this is the weakness that we are looking at in the current Autism Act—that leads to quite serious mental health conditions, including suicide. Of all the conditions that the noble Baroness mentioned, among the autistic community the suicide rate is the highest.

[Baroness Fox of Buckley (Non-Afl)]

I genuinely appreciate that intervention. That is what I think too. It is precisely the inappropriate use of terms such as autism in relation to this overdiagnosis that concerns me, because it is too glibly used. That is part of what I am talking about. I absolutely want those people who need the intervention to get it, but my concern is if it becomes widely used socially, in the way that I did not want to go into in great detail, on university campuses or in society in general. I note the TikTok phenomenon of people getting diagnoses and that being used, and so on. My concern is that the label, the labelling process and the demand for diagnosis and treatment squeeze out the very people that the noble Baroness is talking about.

I too have spent many years trying to distinguish between autism and mental illness. It drives me mad that people do not know the difference. My problem is that, in the debate about this issue, they are very often all lumped together in a way that is medically not clarifying, but the demand for a medical label can mean that people are not even that choosy about which one they get. That is where I have tried to raise an issue.

[Baroness Browning (Con)]

I am very grateful for that response. The noble Baroness said that autism is different; it certainly is different, which is why it has its own Act of Parliament.

--- Later in debate ---

[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?

[Baroness Fox of Buckley (Non-Afl)]

My Lords, very briefly, I will say that I absolutely support this amendment. I think it is worth clarifying what I said earlier about overdiagnosis. The danger is that that can be interpreted as meaning that I want cuts; what I actually want is targeted intervention for the right people, rather than saying, “Oh, everybody’s been calling themselves mentally ill, so let’s cut the services”.

I completely agree with the noble Baroness, Lady Tyler of Enfield, that, if we do not sort out the amount of community provision, what we have done over the last few weeks, never mind the years preceding it, will have been a waste of our time, because the Bill will not be worth the paper it is written on—that is the danger. It is very tempting, in a period of intense economic difficulties, to suggest that this might be one of the first things to go—so I do think this is a very good amendment.

I will remind the House of a discussion we had late the other evening on the plight of prisoners. If there is no community resource for people leaving prison—ex-prisoners—they will deteriorate and end up becoming very ill in the community and being incarcerated again. I discussed that in great detail. In other words, this is essential if we are serious about saying that we do not want to lock people up but, instead, want to treat them appropriately.

[Lord Scriven (LD)]

My Lords, I rise very quickly to support the amendment from the noble Lord, Lord Stevens, and have put my name to it.

I will add a couple of extra things to the noble Lord’s very well-argued case. Modest as it may be, I think it is an effective measure—and this is why I think it is and why the House should support the noble Lord’s amendment if he decides to push it to a vote. It is not that the Secretary of State has announced that the percentage will decrease next year; the percentage decrease happened during this financial year, going down from 9% to 8.78%. So we are now on a trend for the percentage of National Health Service spend on mental health.

Furthermore, one has to question the priority of the Government when they look at the national planning guidance and some of the targets that have been dropped from it. There are no plans to target the 2 million long waiters waiting for mental health care. It would be slightly disingenuous of the Minister, in response, to talk just about the mental health investment scheme, because all it refers to is ICB spend. The uniqueness and cleverness of the amendment from the noble Lord, Lord Stevens, is that it talks about all health service spend, including non-ICB spend, specialised commissioning and other elements that need to be there.

Mental health takes up 20% of illness treated by the NHS, which will probably be spending 8.7%. Because of the trend that is happening, the amendment from the noble Lord, Lord Stevens, is absolutely vital to ensure not just that the percentage is maintained but that the community facilities within this will be funded and implemented.