Mental Health Bill [HL]

Baroness Hollins Excerpts

2nd reading
Monday 25th November 2024 Lords Chamber

[Baroness Hollins (CB)]

My Lords, it is a pleasure to follow the noble Baroness. I remind the House that I worked clinically as a psychiatrist for about 35 years and had been a consultant for two years by the time that the 1983 Act was introduced. I argued then, as now, that mental handicap, as it was called, had no place in legislation—although others disagreed. Profound changes in societal attitudes, alongside advancements in the understanding and treatment of mental illness, have occurred during my career. I agree with the noble Baroness, Lady Barker, and my noble friend Lady Murphy that fusion legislation really should have been considered.

There is no minimum age limit in the Mental Health Act, meaning that its provisions apply to children and young people as well as adults. The Joint Committee, of which I was a member, recognised their unique needs, saying that this is

“a crucial opportunity for the Government to strengthen the rights and protections for children and young people”.

We must never forget that the mental health of babies, children and young people is fundamental to the mental health of the adult population, and that we cannot legislate for the treatment of serious mental disorder without taking mental health seriously from the very beginning of each person’s life.

Psychiatry’s past has included some harmful and forced interventions, rather than the preventive approaches, early intervention and evidence-based treatments that are so needed. The Bill aims to safeguard dignity and autonomy, and ensure best practices for all, including people with learning disabilities and autistic people. A major current concern for me is that there are nearly 2,000 people with a learning disability and autistic people in psychiatric hospitals. Usually, that is because of a lack of individually tailored support and housing—they have an average stay of five years—and because of the shortage of effective treatment options in the community and lack of training for the wider mental health workforce.

My Heart Breaks, the report of a review that I chaired and which was published by the Government last year, shed light on the harrowing realities faced by many of the 100 or so of those 2,000 in hospital who are detained in long-term segregation at any one time. The systemic failures we found reflected a troubling overreliance on detention as a substitute for meaningful care, despite such detentions often lacking therapeutic goals, a pattern that unfortunately affects other patient groups as well, including those with personality disorders.

Historically, policy and practice have overlooked complex intersectional vulnerabilities, including learning disability, autism, gender, race, poverty and physical health issues. Marginalised groups, especially people from racialised communities, are detained more often. Trauma histories may be compounded by the excessive use of medication and restrictive practices which contain people, with an eye to safety, but disempower and just do not support recovery. People need better-adapted psychological therapies but are less likely to access them, and poorly co-ordinated discharge processes further trap individuals in a dysfunctional system. This violates people’s human rights and ethical care standards.

As a long-time advocate for people with learning disabilities and autistic people, for me, one of the Bill’s most significant reforms is the removal of learning disability and autism as stand-alone grounds for detention under Section 3, part 2. This change is complemented by new duties on health and care bodies to provide the community-based support and therapeutic approaches needed to prevent unnecessary detentions. But legislation alone will not provide better care; the right people in the right place with the right skills are needed. So the Bill introduces mandatory care, education and treatment reviews, which aim to create personalised care plans and facilitate timely discharges. Additionally, dynamic support registers are intended to track those at risk of crisis, allowing for early intervention before issues escalate. Advance choice documents could also be valuable for choice, safety and care.

The National Autistic Society, Mencap and several other charities have welcomed the Mental Health Bill as a step toward safeguarding the rights of individuals with learning disabilities and autistic people. All stress the need for robust support systems, including housing and social care. These are essential to prevent unnecessary admissions, emphasising that the Bill’s success depends on effective implementation, accountability and substantial investment in community services. They also request a new action plan to replace the Building the Right Support action plan. This is particularly urgent, given that targets to reduce in-patient numbers of people with a learning disability and autistic people have been repeatedly missed over the last decade, and only one in five integrated care systems have currently met the March 2024 target for reduction of in-patient numbers.

Can the Minister confirm whether a plan such as that being requested will indeed be co-produced and implemented with the help of people with lived experience, families, campaigners and relevant bodies, alongside the implementation of this legislation? Both the Royal College of Psychiatrists and the BPS have cautioned against removing autism and learning disabilities as stand-alone criteria unless there are substantial improvements, warning that this could divert unsupported individuals into emergency services or the criminal justice system. Easy to say, better not to do it—but we must use this as a lever to change the culture of care and support for these groups of people.

We do not want to risk criminalising people’s mental health needs, and we do not want to disproportionately impact already marginalised groups. I ask the Minister, what assurances can Government provide to ensure adequate funding to deliver minimum safe services in the community, such as early prevention measures, rapid response teams, crash pads and effective therapeutic approaches in the community? Indeed, could these alternatives be mandated?

Compulsory detention and treatment of individuals with personality disorders under Part 2 of the Mental Health Act is another issue. Personality disorders stem from relational difficulties and cannot be effectively treated in restrictive in-patient settings. Research shows that admissions without structured, evidence-based psychological interventions provide no benefits and can indeed worsen symptoms.

Why is Section 117 aftercare limited to Section 3? Social and health care should be integrated for all patients based on need, not the section they were detained under. For example, a financial crisis causing suicidal thoughts in a farmer might lead to a Section 2, when a social prescription might have been effective. After assessment, they will return to the same situation without appropriate support, such as legal or financial advice to resolve the crisis.

The new Mental Health Bill gives us an opportunity to address the stigma that shaped policy in the 1980s and create a legal framework which keeps pace with scientific advancements. We need to reframe our focus from risk management to supporting accessible, evidence-based community interventions, ensuring that care aligns with ethical and therapeutic principles and prioritises a rights-based, person-centred approach.

Our actions now will shape mental health care for the 21st century. Let us enact compassionate and progressive reforms that future generations will respect.

Palliative and End-of-life Care: Funding

Baroness Hollins Excerpts

Wednesday 4th September 2024 Lords Chamber

[Baroness Merron (Lab)]

The noble Baroness is quite right to raise this, and I can give her that assurance. She raises the point about identification of people with specific needs. I am interested to see that there are some very good examples of local good practice—for example, in Dorset, where they have proactively gone out to identify who needs palliative and end-of-life care. By so doing, they have raised the percentage of the local population who should be receiving it. That is a model we will want to look at. With regard to those who have particular needs, as the noble Baroness describes, I think that model will be helpful too.

[Baroness Hollins (CB)]

My Lords, the Minister has rightly pointed to the growing need for excellent palliative care close to home, and I am glad of that, but I wonder whether she is aware of the Hospice UK report pointing to the number of redundancies occurring across the sector. In the context of the 2022 Act, which required the NHS to commission adequate NHS care, this seems to be rather urgent, not just to provide good care for people but to reduce the impact on the acute hospital sector of not providing palliative care.

[Baroness Merron (Lab)]

The noble Baroness is right in her observations, and we certainly recognise that times are difficult, particularly for many voluntary and charitable organisations including hospices, for example, due to the increased cost of living. We are working alongside key partners and NHS England to proactively engage with stakeholders, including the voluntary sector and independent hospices, because we want to understand the issues they face and to seek solutions to them.