Women’s Health Strategy

Baroness Merron Excerpts

Tuesday 4th February 2025 Lords Chamber

[Baroness Stedman-Scott (Con)]

My Lords, nearly 600,000 women are waiting for treatment on a gynaecological waiting list in England. Labour’s 2024 general election manifesto made a commitment that:

“Never again will women’s health be neglected. Labour will prioritise women’s health as we reform the NHS”.


Why, then, are the Government removing the requirement on integrated care boards to implement women’s health hubs? The Answer given to this Urgent Question by the Minister in the other place stated that at least 90% of ICBs already have women’s health hubs, which is terrific. If they have been rolled out so effectively, why not complete the job and follow through to reach 100%? Perhaps the Minister could tell us what exciting plans she has to do this.

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

I would be glad to give information to the noble Baroness, whom I thank for reminding your Lordships’ House of the situation that we inherited—600,000 women on gynaecological waiting lists—and the challenge before us. My honourable friend in the other place was quite right about the planning guidance, but I commend the effort of the noble Baroness’s Government for pump-priming the introduction of women’s health hubs to the point where there are some 80 across the country—in nine out of 10 areas, there is at least one. It was never a long-term planning situation. The noble Baroness will also be aware of the informed observation from the noble Lord, Lord Darzi, that planning guidance has too many specifics. We therefore needed a new approach, which is what we have done. The planning guidance is not the catalogue of all the levers, nor of all that happens, in the NHS.

[Baroness Barker (LD)]

My Lords, women’s health hubs have proved enormously popular with practitioners, who are able to give multiple treatments in one session, and with women, who no longer have to take time off on different days to go to different clinics for different procedures. Given this, why are the Government not backing this cost-effective strategy, not least because it prevents women showing up at A&E, which is far more expensive?

[Baroness Merron (Lab)]

We are not closing women’s health hubs—it is important to put that on record. I have already said how successful the pilot has been; it therefore does not require a further target. I hope that noble Lords have seen that the changes to the planning guidance move away from the old centralised operating model to give more control and direction locally. As I said, the decision not to mandate women’s health hubs reflects a new approach to the guidance: fewer national directives and more empowerment of local leaders. Women’s health hubs are also described in the elective reform plan, which is one example of another area where their importance is recognised and boosted.

[Baroness Sugg (Con)]

My Lords, the Minister will know that women’s health hubs are vital in reducing gynaecological waiting lists. We have seen that through their success in areas such as Birmingham, Tower Hamlets and Liverpool. I hear what the Minister has been saying, but there is strong concern from the sector that many of the existing hubs are in their infancy or are not yet operational. They will not progress unless there is operational guidance for the NHS or formal commitment to them from the Government. With their removal from the planning guidance, what actions is the Minister taking to ensure that every ICB has a women’s hub? Given what she said about local decision-making, what steps are being taken to make sure that we learn from the success of the highest-performing hubs and share it with others?

[Baroness Merron (Lab)]

We continue to learn from the best. I am committed to speaking with the leadership of ICBs about the importance of women’s health hubs, not least because it is about improving women’s healthcare. Having visited a women’s health hub myself, I can testify to the points that the noble Baronesses have made. However, I gently repeat that we need to look not just in the planning guidance but in the elective reform plan, which states about the NHS that:

“In gynaecology we will support … innovative models offering patients care closer to home”.


That is exemplified by the women’s health hub. The Neighbourhood Health Guidelines, published just last week, include women’s health hubs as an example of a neighbourhood health model.

[Baroness Blackwood of North Oxford (Con)]

My Lords, the history of health policy through successive Governments has been one of too many priorities and targets which are not delivered, so I support the Government in this analysis. It has also been one of poorer outcomes for women and minorities. Given the shift in leadership from the Department of Health and others, how will the Government ensure better outcomes for women and minorities? How will those be monitored? Will they intervene early if they do not see that direction of travel?

[Baroness Merron (Lab)]

I thank the noble Baroness for her welcome for the new approach in the planning guidance. As she commented, and as noble Lords opposite will know, just because something is in the guidance does not mean that it will happen. For example, despite targets for A&E performance or ambulance response times being written into planning, they were not delivered. This is not where we want to be. We will continue to work with NHS England; for example, to ensure that women’s health is key. I should also emphasise that, as we move towards the 10-year health plan, women’s health will feature not as an adjunct but run throughout.

[Baroness Hussein-Ece (LD)]

My Lords, I welcome the Minister’s comments. We know that black women are three to four times more likely to die during childbirth and that the rate of maternal deaths in the UK has risen during the past 10 years, which I am sure she will agree is a national disgrace. Does she therefore accept that women—and especially women of colour—have been ill served for many years? How will the Government reverse this trend?

[Baroness Merron (Lab)]

I agree with the noble Baroness. It is a disgrace that there is such a huge inequality in maternity care. Maternal mortality rates are some 2.3 times higher for black women and 1.4 times higher for Asian women, while those living in the most deprived areas have a maternal mortality rate nearly twice as high as that for those who live in the least deprived areas. That cannot be acceptable in 2025. I am glad that we have taken a number of actions to ensure that trusts who fail on maternity care are robustly supported. We will set an explicit target to close black and Asian maternal mortality gaps. Trusts are also required to publish a suitable plan to tackle this and to put it into action. It is a challenge, but not one that we shy away from.

[Baroness Blackstone (Lab)]

My Lords, I declare my interest as set out in the register. What is the Government’s timetable for a revised or updated version of the women’s health strategy? Can the Minister also assure the House that there will be adequate funding for its implementation when it is brought in?

[Baroness Merron (Lab)]

Let me assure my noble friend and other noble Lords that there are no plans to cancel the women’s health strategy. I know my noble friend did not say that, but it is very important to put that on record. We continue to implement it; for example, since I have been in post, through measures such as supporting pregnancy loss through a full rollout of baby loss certificates, introducing menopause support in the workplace, and boosting women’s participation in research and clinical trials. As I said, our priorities for delivering the strategy will be through the 10-year plan. Funding decisions will be announced in due course.

[Baroness Hodgson of Abinger (Con)]

My Lords, given that one-third of all new breast cancer cases occur in women over the age of 70, will the Minister consider extending automatic screening for those women? At the moment, it stops at that age.

[Baroness Merron (Lab)]

Women over 70 can request an assessment if they feel it is appropriate for them. We act on and apply the scientific advice and evidence that we are given. On World Cancer Day, perhaps it would be appropriate to say to the noble Baroness that some 700,000 women across the country will take part in a world-leading trial to test our cutting-edge AI tools, which will be used to catch breast cancer cases earlier. This morning, I was at the Royal Marsden Hospital in Sutton with Minister Vallance to see the incredible contribution that AI is making to improved cancer services, including for women.

Mental Health Treatment: Waiting Times

Baroness Merron Excerpts

Monday 3rd February 2025 Lords Chamber

[Baroness Warwick of Undercliffe]

To ask His Majesty’s Government what plans they have to reduce the waiting time for access to mental health treatment.

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

My Lords, I am pleased to be answering this Question during Children’s Mental Health Week. To ensure that high-quality support can be accessed in a timely manner, among other actions we are committed to recruiting 8,500 more mental health workers to cut waiting times, introducing access to specialist mental health professionals in every school and rolling out young futures hubs in every community.

[Baroness Warwick of Undercliffe (Lab)]

My Lords, I thank the Minister for that helpful reply. There has been a 33% rise in mental health referrals since 2019 and it is particularly severe for children and young people, with an increase from 12% to 20% for those experiencing mental health conditions. This has not been matched by an increase in investment in services or additional staff to enable early intervention and speedy help. Many children have been forced to wait till their conditions escalate, putting a lot more pressure and exceptional demand on school counsellors and on community care. Can the Minister say exactly what the Government are doing to address these pressures, particularly on young people? How will she ensure that funding at local level will focus on their needs?

[Baroness Merron (Lab)]

I agree with my noble friend’s assessment of the impact of what is a totally unacceptable situation, particularly for children and young people. On the point about ensuring delivery locally, I refer your Lordships’ House to the NHS planning guidance, published last week, which not only confirms our commitment to the mental health investment standard but sets out an objective to increase the numbers of children and young people under 25 accessing services in the forthcoming year compared to 2019.

[Lord Carlile of Berriew (CB)]

Does the Minister agree that the long delays experienced by released prisoners in accessing necessary mental health care simply oil the revolving door of their return to prison? Will the Government give high priority to dealing with that problem?

[Baroness Merron (Lab)]

We are extremely aware of the point the noble Lord helpfully makes. The matter of severe mental illness in prisoners has come up repeatedly in Committee on the Mental Health Bill, and we will continue to work to address the points he raised.

[Baroness Tyler of Enfield (LD)]

My Lords, I welcome the fact that the new NHS operational planning guidance, which the Minister just referred to, includes targets for improving mental health care, learning disabilities and autism. What assurances can the Minister give that these targets will be properly reflected in the forthcoming spending review, the NHS 10-year plan and the updated NHS workforce plan to ensure we really do see parity of esteem between physical and mental health?

[Baroness Merron (Lab)]

I can confirm the commitment of the Government to parity of esteem between mental and physical health services, as was outlined in our first programme of legislation confirmed in the King’s Speech. It will have absolute regard in all the areas the noble Baroness refers to. I know she is aware that I cannot comment specifically on spending reviews, but all that will be announced publicly in due course.

[Baroness Meacher (CB)]

My Lords, ADHD affects lots of children and, though treatable, it is often not treated. Can the Minister assure the House that treatment for ADHD will increase substantially to ensure children can get back to school and get on with their studies?

[Baroness Merron (Lab)]

It is important that children with ADHD receive the right education and the right support. We are working with the Department for Education to make sure that happens.

[Lord Davies of Brixton (Lab)]

I welcome my noble friend the Minister’s replies to the questions asked. I know she is personally committed to improving the services provided to people suffering from problems with their mental health. However, is she aware of the concern that has been expressed by the Royal College of Psychiatrists that the increased autonomy allowed to local health authorities will, without clear guidance, lead to inadequate investment in mental health services? Can she provide some reassurance for the royal college?

[Baroness Merron (Lab)]

I am grateful to my noble friend for raising this. There are whole areas in which we are seeking to turn this round, and I know my noble friend is aware of the challenges we face. To highlight just one, I refer him to the fact that the Government have chosen to prioritise funding for talking therapies and to deliver that expansion. That is really important because, in all of this, we have to make the move from dealing with sickness to prevention, and I believe this is a very strong example of how we can do that.

[Lord Laming (CB)]

My Lords, does the Minister agree that, in mental health services, the gap between referral and treatment is getting longer and longer, and that delay is leading to a marked deterioration in the patient’s experience? So far as young people are concerned, the delay has become incredibly long. Can the Minister assure the House that thought is being given to reducing the gap between referral and treatment?

[Baroness Merron (Lab)]

The noble Lord makes a very important point. This is one of the many areas where long waiting lists and delays in people receiving the necessary service are creating additional pressures on the individual, communities and the NHS. We are doing work in a number of areas, such as ensuring that NHS 111 can provide for those in crisis, or those concerned about a family member or loved one, so they can speak to a trained mental health professional. We are constantly looking at and providing new ways for people to get more instant access.

[Earl Howe (Con)]

My Lords, do the Government see a role for employers in promoting the mental health of their respective workforces?

[Baroness Merron (Lab)]

I certainly do, and with the NHS being such a large employer, that is one of the areas that we will be attending to. The long-term workforce plan will provide its report around the summer of this year and there will be much detail on how the workforce will be but also on the ways that we can improve its health and retention as well as recruitment.

[Baroness Winterton of Doncaster (Lab)]

My Lords, my noble friend Lady Warwick spoke particularly about young people and provision in schools. Does my noble friend the Minister agree that there is a key role for educational psychologists and school nurses in ensuring that diagnosis can take place early? Does she believe there could be a greater role for academies and schools working together at local level to provide that type of provision?

[Baroness Merron (Lab)]

I agree with my noble friend’s suggestions. Of course it is a team that provides the mental health support that is necessary, but I am particularly pleased that we are working to deliver a mental health professional in every school. That is a starting point, not necessarily the end point, so my noble friend makes some very helpful suggestions.

[Lord Markham (Con)]

I appreciate from my own time as Health Minister how difficult it is to meet the expanding demand, so I wonder if we are still looking at other methods to expand capacity, particularly digitally, both in terms of early diagnosis but also some of the digital mental health treatments which are quite impressive?

[Baroness Merron (Lab)]

I am glad for the understanding of the noble Lord. NHS England is encouraging the local use of digital tools, for example digitally enabled therapies, and it is an extremely helpful way also of managing waiting lists so people are not just left waiting but they are held and supported, often through digital means.

[Lord Paddick (Non-Afl)]

My Lords, I declare my interest as set out in the register. A policy of the police not attending mental health incidents, called “right care, right person”, was developed by Humberside Police and adopted by the Metropolitan Police. What assessment has been made of the impact of this policy on those suffering from mental health issues?

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[Baroness Merron (Lab)]

I thank the noble Lord. Again, this is an area which has been explored in Committee on the Mental Health Bill and we are looking at the results of how that is working out, because we have to get the balance right between supporting people in crisis and also ensuring that the right professionals are in place.

Musculoskeletal Health

Baroness Merron Excerpts

Thursday 30th January 2025 Lords Chamber

[Lord Black of Brentwood (Con)]

My Lords, in begging leave to ask the Question standing in my name on the Order Paper, I note my interest as co-chairman of the APPG on osteoporosis.

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

My Lords, improving health outcomes for the more than 17 million people in England with musculoskeletal conditions forms a key part of this Government’s missions to build an NHS fit for the future and kick-start economic growth. We are making a start by delivering a joint programme with the DWP—entitled Getting It Right First Time, the MSK community delivery programme—and working with integrated care board leaders to reduce NHS community waiting times and to improve data metrics and referral pathways.

[Lord Black of Brentwood (Con)]

My Lords, osteoporosis is one of the gravest musculoskeletal conditions, because fractures ruin lives and kill people. Can the Minister understand the frustration so many feel that, after years of promises, there is still no prospect of universal access to life-saving fracture liaison services in England? Each time this House debates osteoporosis, there is unanimous support and Ministers of both parties stand here and promise action. Each time there is an election, commitments are made, including one by the Secretary of State that rollout would be one of his first acts in post. Well, it was not, and 1,100 people have died since then. Will the Minister, without prevarication or diversion about widening access, specifically restate the Government’s commitment to universal rollout of FLS in England by 2030? If not, could she explain to thousands suffering often intolerable pain or grieving loved ones why they have reneged on it?

[Baroness Merron (Lab)]

I pay tribute to the noble Lord’s campaigning, which is impressive in maintaining focus on what I regard as a very important area. He may be aware, but I draw it to his and your Lordships’ House’s attention, that a Written Ministerial Statement about addressing urgent challenges was laid today. It outlines the fact that planning guidance is soon to be published—it was not published as I entered the Chamber—and will reflect patient priorities that are important to those who have to contend with osteoporosis. These include cutting waiting times, improving access to primary care—bearing in mind that 30% of GP appointments are related to MSK—and improving urgent and emergency care. On the point the noble Lord asks about, as I have said before, we are working closely to consider a whole range of options to provide better quality and access to important preventive services as part of ending the postcode lottery. I will be pleased to keep him informed.

[Baroness Donaghy (Lab)]

My Lords—

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[Baroness Donaghy (Lab)]

I am a member of the APPG on osteoporosis, and we are very worried that fracture liaison services have been deprioritised in the recent NHS planning guidance. We know that the pump-priming transformation fund works because we have seen it working in Wales. It saves lives, as the noble Lord, Lord Black, said, releases people into the labour market, releases beds in hospitals and improves quality of life for thousands of people. Can the Minister give us an assurance? If this milestone has been missed in the planning guidance, we need urgent clarity on how the 2030 target will be reached.

[Baroness Merron (Lab)]

My noble friend raises a number of important points. In reference to the planning guidance, I hope she will understand that at this stage that is leaked information and I am therefore not in a position to comment. The Secretary of State has confirmed that planning guidance will be published in due course. I agree that patients around the country are waiting too long for care and treatment. I draw my noble friend’s attention to the plan for change, which will get the health service back on its feet. Part of the elective recovery plan, published just a few weeks ago, sets out funding to boost DEXA, which is bone density scanning capacity to support improvements in bone health and early diagnosis, including for osteoporosis. That will provide an estimated 29,000 extra scans per year, so I hope my noble friend will take heart from that node of direction.

[Lord Pannick (CB)]

My Lords, I declare a family interest in this condition. Will the Minister recognise that the failure to roll out the much-needed early diagnostic service, which, as the noble Lord, Lord Black, said, was promised during the general election campaign, will inevitably result in greater cost to the NHS in the years to come?

[Baroness Merron (Lab)]

I certainly agree with the noble Lord that without the right services in place at the right time and in the right location, there is additional cost—not just to the NHS but to the economy and to individuals. We have found that musculoskeletal community services have the largest waiting lists in England, and I refer the noble Lord to our forthcoming 10-year plan on the move from hospital to community. That will be a key part of cutting waiting lists, and the measures I have already announced will also assist.

[Lord Lexden (Con)]

My Lords, did not the Health Secretary give an unequivocal commitment at last year’s general election that there would be universal fracture liaison services by 2030, with implementation starting immediately? Does that commitment still stand?

[Baroness Merron (Lab)]

I thank the noble Lord for allowing me to reiterate that the department is working closely with NHS England to look at a whole range of options to provide better-quality care and access to those important preventive services. I emphasise that this is part of ending the postcode lottery. I remind your Lordships’ House that integrated care boards are responsible for the delivery of these services. We will continue with the further actions that we are taking, some of which I have already referred to, which will ensure that patients are getting the service they need.

[Baroness Burt of Solihull (LD)]

Integrated Care Journal has indicated the potential to improve access pathways, giving an example of an AI physiotherapist service at home and covered by CQC. Will the Government develop and adapt something like this?

[Baroness Merron (Lab)]

The noble Baroness raises an interesting point and I will be happy to look into what she suggests. I know she is aware that one of the main pillars of change will be about analogue to digital, and in that I put the contribution of AI. Just this afternoon I will speak to a conference about the role of AI in respect of women’s health, and osteoporosis will be very much part of that.

[The Senior Deputy Speaker (Lord Gardiner of Kimble)]

My Lords, I invite the noble Lord, Lord Campbell-Savours, to speak remotely.

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[Lord Campbell-Savours (Lab) [V]]

As a sufferer of ankylosing spondylitis, a painful spinal musculoskeletal condition aggravated by a lack of physical movement, I can report that inactivity in underemployment can severely aggravate the condition. Would the state benefits system not be far better served if multi-patient group physio services and collective patient gyms—even open-air ones, as in the Far East—were available on a wider scale? Greater collective patient activity for this and other similar groups in large public venues would save money in the benefits system.

[Baroness Merron (Lab)]

My noble friend raises a very important point from a position of a lot of experience. I can confirm that we recognise the importance of regular physical activity for those with MSK conditions. It helps to reduce pain and disability as well as improving well-being and helping with other conditions. The existence of MSK hubs with a non-healthcare workforce delivering physical activity-based interventions has been extremely helpful, and we will continue to encourage that and explore the role that hubs can play.

[Lord Kamall (Con)]

My Lords, we should pay tribute to my noble friend Lord Black for all his hard work in this area. I do not think the Minister answered his Question. On Tuesday evening she told the House she wanted to be honest, so in that spirit can she tell your Lordships whether the Government have agreed new dates, first, to begin the rollout and, secondly, to achieve universal fracture liaison services? If so, what are those dates? If not, can she tell us when we will have those dates, so that all the people waiting for these services are clearer about what they can look forward to?

[Baroness Merron (Lab)]

I am afraid I cannot give the noble Lord the dates that he seeks, but I will be pleased to keep him updated on the development of services.

Young Disabled People: Social Care Services

Baroness Merron Excerpts

Tuesday 28th January 2025 Lords Chamber

[Baroness Monckton of Dallington Forest]

To ask His Majesty’s Government what plans they have to address demand for support from young, disabled people and their families, particularly in relation to provision of social care services, as they transition to adulthood.

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

My Lords, the Government recognise the difficulties that young disabled people and their families can face when they transition into adult social care. This has been a neglected area, which is why the Department of Health and Social Care is now working across government to identify opportunities to better support young people and their families at this crucial stage in their lives. My ministerial colleague, the Minister for Care, Stephen Kinnock, has recently met his counterpart at the Department for Education to discuss how the two departments can make progress on this issue.

[Baroness Monckton of Dallington Forest (Con)]

My Lords, for many people with learning disabilities, transition into adulthood is purely chronological. Their needs and care requirements remain exactly the same. Parents have described this transition into post-18 services as like jumping off a cliff.

I was approached by the parents of Cameron, a young man with severe learning disabilities. Melanie, his mother, was a nurse for 30 years, and his father, David, was a Royal Marine commando who fought in three wars. Their professional life serving the community and their country has not prepared them for the battle they are facing with Somerset Council to get the right accommodation for their son. Melanie told me that the day he turned 18, all support fell away. Will the Minister accept that these are the same people, with the same condition and the same continuing needs, and that, as part of adult social care reform, there needs to be a separate category for people with learning disabilities, who are so neglected? In this spirit, would His Majesty’s Government consider a Minister for learning disabilities?

[Baroness Merron (Lab)]

I understand and am sympathetic to the points that the noble Baroness makes about Cameron and his family. I listened very closely to the concerns that she raised. As I mentioned in my Answer, we are very aware and absolutely accept that the services are not in the places they need to be. That is why I made the commitment to work closely with the relevant department.

Looking to the future, as recently as November we published what I regard as a very ambitious and wide-ranging whole-system plan, called Keeping Children Safe, Helping Families Thrive. It seeks to break the cycle of crisis intervention and to rebalance the system back towards earlier help for families, which I hope would have been helpful in the situation the noble Baroness describes. All local authorities, including Somerset, have to set out the support available for those with special educational needs and disabilities as they move into adulthood.

[Baroness Walmsley (LD)]

My Lords, the duty of local authorities to carry out a transition assessment includes whether the child, or their carer, is likely to have needs for care and support after the child in question becomes 18. In the light of that, what resources and guidance are the Government giving to local authorities about the needs of the carers of those transitioning to adulthood? Does the complexity of this whole issue not indicate the need for care co-ordination?

[Baroness Merron (Lab)]

It certainly does. The noble Baroness has been positive about the plans that we have for the independent commission, led by the noble Baroness, Lady Casey, to resolve once and for all, on a cross-party basis, adult social care. The noble Baroness makes a very good point about the role of carers. Indeed, when we think of a young carer particularly, it is crucial that their needs are considered and that support is given. It is part of the whole way in which we support someone who needs social care, no matter what their age.

[Lord Laming (CB)]

My Lords, when the Public Services Committee took evidence on the transitional arrangements for young people with disabilities, we experienced two extremes in that evidence. One was that the transfer from education services to social care services was badly handled in a lot of authorities. As the noble Baroness, Lady Monckton, said, it felt like falling off a cliff, with young people then described as unemployable. The second, which was quite inspiring, was where local authorities had established a local hub where employers could meet these young people. They discovered there things that could benefit both sides, and that the young people blossomed in work. Will the Minister do everything possible to encourage the second?

[Baroness Merron (Lab)]

The noble Lord is correct to reference the committee’s findings. People should not be written off as unable to work. It is about getting the right support in place, with the right provisions and at the right time. I certainly share his view. That is why we are working across government to achieve the very thing that he talks about.

[Baroness Pitkeathley (Lab)]

My Lords, I was with someone this morning who has a son at this stage and was told that the earliest time when they could have a transition interview would be December 2026. In the meantime, the only support they are getting is from the local branch of Mencap. As well as co-operation between health and social care, will the Government commit to supporting the voluntary sector, which provides such important services in this regard?

[Baroness Merron (Lab)]

I have direct experience of the value of charities such as Mencap, and I thank it and all the other third sector organisations involved. I agree with my noble friend about the need to incorporate all sectors. That is the only way that we will provide the right provision in a timely fashion.

[Lord Kamall (Con)]

My Lords, we know it is true not only for this care service but for many health and care services that there is often concern when, upon reaching adulthood, the patient has to move from paediatric care to adult services—we have had a number of debates on that in this House. Often, that can involve a change of medical staff, from a clinician or caseworker who knows the patient to someone who is a stranger, as it were. Can the Minister tell noble Lords what guidance there is for the clinician or the health worker looking after the child, as well as for the clinician who will be looking after the child when they are an adult, whereby they talk to each other to ensure as smooth a transition as possible?

[Baroness Merron (Lab)]

The transition assessment has to cover the whole range of provision, including healthcare, as the noble Lord rightly says. That is already embedded. I refer back to the point of my noble friend: it is indeed true that there are long waiting lists for transition assessments, which is far from ideal. This means that people are suffering from late planning and insufficient support, which we want to put right, no matter where the requirement comes from, whether it is in health, education or employment.

[Lord Alton of Liverpool (CB)]

The Minister may recall that, in 2022, the Down Syndrome Act was passed by your Lordships’ House, having been introduced in another place by Sir Liam Fox MP and in this House by my noble friend Lady Hollins. Can the Minister tell us how far we have got in implementing the terms of that Act, especially in helping those with Down syndrome to find employment in the workplace?

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[Baroness Merron (Lab)]

It is a good point. I will be pleased to look into it in greater detail and write to the noble Lord.

[Baroness Uddin (Non-Afl)]

My Lords, I had not intended to speak but I want to reach out to the noble Baroness, Lady Monckton, as I understand her frustration and why she is upset. I declare an interest as a mother of a child in this situation—he is now an adult, at 46 years old. That is precisely what happened to my family and my son; the service was no longer fit for purpose. There are hundreds and thousands of parents feeling exactly the same angst. Will the Minister’s review therefore build in space for advocacy on behalf of parents in any forward-looking strategy that the Government are considering?

[Baroness Merron (Lab)]

The role of advocacy is extremely important. I take on board what the noble Baroness is saying.

[Baroness Bull (CB)]

My Lords, can the Minister say what the Government are doing to persuade employers of the value of employing a diverse workforce, including those with learning disabilities?

[Baroness Merron (Lab)]

I would be pleased to get some specific detail, but I agree with the noble Baroness—there are huge benefits both ways, as was said earlier. We are keen to promote and support this, to get as many people into employment as possible, and to let employers benefit. I will gladly write to the noble Baroness.

Community Pharmacy Closures

Baroness Merron Excerpts

Tuesday 28th January 2025 Lords Chamber

[Baroness Bakewell of Hardington Mandeville]

To ask His Majesty’s Government what plans they have to prevent community pharmacy closures.

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

My Lords, the Government recognise that pharmacies are integral to the fabric of our communities. They provide an easily accessible front door to the NHS and are staffed by highly trained and skilled healthcare professionals. We have now recommenced the consultation with Community Pharmacy England on funding arrangements, which was not able to be concluded before the general election.

[Baroness Bakewell of Hardington Mandeville (LD)]

I thank the Minister for her response. Since 2017, there has been a net loss of 1,200 pharmacies in England, with 35% of closures occurring in 20% of the most deprived areas. The annual funding shortfall in England stands in excess of £100,000 per pharmacy—a rise from £67,000 since 2023. Between September 2022 and June 2024, the annual loss of pharmacy access was 3.4 million hours. Given this, does the Minister believe that pharmacies are in a healthy state to support the Pharmacy First service?

[Baroness Merron (Lab)]

Some 98% of pharmacies are signed up to Pharmacy First and I am glad about how it is developing. On the noble Baroness’s very real points, the majority of recent closures were the result of large pharmacy chains optimising their portfolios. As she is aware, community pharmacies are private businesses, although they earn most their income from the NHS. Those business models vary significantly.

Local authorities are required to undertake a pharmaceutical needs assessment every three years to assess whether the population is being served. Integrated care boards have to give regard to those needs assessments when they review applications from new contractors and seek to fill any gaps. This continues to be work in progress to which we must be alert, but it is also important to look at some of the reasons for the closures.

[Lord Fowler (CB)]

My Lords, is it not true that we have not used community pharmacies in this country to their full potential? That impression was confirmed for me when I was chairman of such a group. Should our policy not be to develop community pharmacies so that they make an even bigger contribution to public health in this country? Would it not be better if pharmacists’ income came from that kind of effort, rather than from asking them to rely on the sale of cosmetics and other over the counter, commercial products?

[Baroness Merron (Lab)]

Commercial over the counter products will have a part to play. However, I take the point that the noble Lord makes. I am sure it is true that their vital role, and the opportunities that they offer, were not exploited as much as they could have been—when I say “exploited”, I mean that in a positive way. The Minister for Care, Stephen Kinnock, issued a press release today. In his last point he says:

“I am committed to working closely with Community Pharmacy England to agree a package of funding that is reflective of the important support that they provide to patients up and down the country. I am confident that together we can get the sector back on its feet and fit for pharmacies and patients long into the future”.

[Baroness Winterton of Doncaster (Lab)]

My Lords, the Government are on the right track in recognising the role that community pharmacists can play in public health by preventing illness and reducing the number of people turning up at A&E. However, is my noble friend the Minister aware of reports that some GPs have been unwilling to direct patients to community pharmacists, even under the Pharmacy First programme? Will she look at whether further action is needed to ensure that GPs work with community pharmacists to deliver services to patients?

[Baroness Merron (Lab)]

I am aware of the reports that my noble friend refers to. This is a new service; it needs to bed in. NHSE is working closely with ICBs, GPs and the community pharmacy sector to improve referrals. Funding has also been provided to ICBs for primary care network engagement leads, who should be well placed to support GP teams to refer into the service. We are aware of my noble friend’s point; we are acting on it and we will continue to keep it under review.

[Lord Lansley (Con)]

Further to that important point, will the Government guide ICBs to commission additional services from pharmacies? They have often not been commissioned with a sustainable funding model. Dispensing is not enough. They can provide important preventive services and minor illness services. However, they need the commissioning revenue to enable them to sustain their position.

[Baroness Merron (Lab)]

That point is understood, which is why I thought it important to bring to your Lordships’ House the announcement in the media release from my ministerial colleague Stephen Kinnock. As I mentioned in answer to an earlier question, integrated care boards have a role to play. They should—in fact, they are required to—have regard to the pharmaceutical needs assessment conducted every three years by local authorities. That ought to identify where there are gaps and allow consideration of how to fill any such gaps.

[Baroness Finlay of Llandaff (CB)]

My Lords, given the estimate that community pharmacies save some 38 million consultations that would otherwise have been in general practice each year, and the fact that 97% of pharmacy staff report shortages in accessing different medicines as prescribed, how are the Government planning to allow community pharmacies to adjust medicines—as has been recommended by Community Pharmacy England—so that they can modify prescriptions, rather than spend time recontacting the GP when they are themselves familiar with the items?

[Baroness Merron (Lab)]

The noble Baroness raises a good point and work is continuing to resolve that. It might also be helpful to say that NHS England has commissioned an economic analysis of the cost of providing pharmaceutical services and that will inform future funding arrangements. I say that in answer to the point the noble Baroness made about the potential savings that can accrue if we maximise the role of pharmacies.

[Lord Kamall (Con)]

My Lords, I understand the point that the Minister made about large chains rationalising their portfolios of premises. Have the Government and the NHS looked into whether the extra money made available to pharmacies from the Pharmacy First programme can make these pharmacies viable where they would not have been before? Secondly, what conversations are NHS England and the department having with retailers, community hubs or, where feasible, GP surgeries to provide local community pharmacy services in partnership with them?

[Baroness Merron (Lab)]

The economic analysis by NHS England that I just referred to will be helpful in informing where we go next. I confess that I did not get all the detail of the noble Lord’s second point, so I will look at it in Hansard and I will be pleased to write to him.

[Baroness Humphreys (LD)]

Community pharmacy owners rated medicine supply instability as the most severe pressure their businesses face. This instability puts operational pressures on pharmacies and financial pressures on businesses, and for patients it can mean alarming delays. What measures are the Government taking to address the problems of medicine supply and their impact on hard-pressed community pharmacies?

[Baroness Merron (Lab)]

I recognise that, as the noble Baroness says, there are some difficulties with the supplies of certain medicines. That has been going on for some time. We are therefore working to ensure that the supply chain is secure and robust and can meet the demands on it, which requires a detailed look. Work will continue, and I look forward to continuing to update your Lordships’ House about that.

[Lord Watts (Lab)]

My Lords, is it not the case that the present health structures are not suitable for purpose? Do we not need to look at providing health centres that include a pharmacy, dentists, doctors and all other services in one place to get the maximum resources to the public?

[Baroness Merron (Lab)]

My noble friend will be glad to know that bringing services together under one roof and designing them around the patient is exactly where this Government are going. I ask him to keep an eye out for the 10-year plan, which will address many of the points that he is making.

New Hospital Programme Review

Baroness Merron Excerpts

Tuesday 28th January 2025 Lords Chamber

[Lord Scriven (LD)]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[Lord Mott (Con)]

My Lords, I welcome the £102 million that the Minister referred to for the upgrade to GP estates. May I ask how many of those will be in Cambridgeshire? Has any assessment been made of the pressure that the upgrade of those GP estates will take off the NHS? The Minister said that often people cannot get a GP appointment and therefore tend to go to A&E. Has any assessment been made of how much pressure will be taken off and, more importantly, the quality of care given to people who are able to go to their local GP instead of having often to go to A&E?

[Baroness Merron (Lab)]

While I cannot answer exactly on Cambridgeshire, which the noble Lord raises, I can say that the department and NHS England are working with integrated care boards to ensure that there is a priority on high-impact projects where investment will unlock all the things we are all looking for, which are significant productivity gains and additional usable space from existing buildings. Of course, ICBs are responsible for that. I perhaps should also make the point that this is the first dedicated national capital fund for primary care since 2020. The noble Lord rightly quoted me back about the benefits of investing in GP practice. We are probably all familiar with that. There have been a number of reviews, including, of course, the independent review of the noble Lord, Lord Darzi, which spoke to the point about the need for capital investment in primary care.

[Lord Liddle (Lab)]

My Lords, will my noble friend the Minister and the ministerial team at health accept my congratulations that they have had the courage to come up with a realistic programme, whereas what we had before was fantasy? This is very important. I read the Darzi report, and it has been clear that for years capital money has been used in order to fill revenue gaps at the end of the year because, basically, the whole system was underfunded. It is also clear that, as well as wanting to put the estate and buildings right, there is a tremendous need for investment in hospital equipment, scanners and all the rest in order to improve quickly the effectiveness of delivering good services to patients, and that the Government have to balance these pressures. It looks to me as though they are doing it right.

[Baroness Merron (Lab)]

I am, of course, delighted to accept the thanks from my noble friend, and I will indeed share it with the ministerial team. As has already been raised by the noble Lord, Lord Scriven, and as my noble friend has pointed out, robbing Peter to pay Paul does nothing; productivity, safety, quality of care and providing services, including tackling waiting lists, requires investment in capital and dealing with the state of buildings and the estate. I am sure that we have all seen many examples of where failure to invest has not helped at all. I am glad that my noble friend welcomes the investment that we are making, not just in new surgical hubs but scanners, beds and new radiotherapy machines to improve cancer treatment. All these are about tackling the waiting lists because we inherited the highest ever waiting lists and the lowest-ever patient satisfaction, and we are determined to turn that around.

[Lord in Waiting/Government Whip (Lord Cryer)]

My Lords, the annunciator tells me that Report is not due to begin again until 8.07 pm. Since the Statement fell short of the anticipated 40 minutes, I beg to move, from a packed House of Lords, that we adjourn during pleasure until 8.07 pm.

Mental Health Bill [HL]

Baroness Merron Excerpts

Committee stage
Monday 27th January 2025 Lords Chamber

[Earl Howe (Con)]

My Lords, I believe we would all accept—and, personally, I am in no doubt—that my noble friend Lady Browning possesses a breadth and depth of experience in matters relating to autism and learning disability. By that, I mean that she has not just a familiarity with the day-to-day challenges of life for individuals with one or more of these conditions but a knowledge of the practical frustrations and hurdles that often have to be overcome if the best interests of such individuals are to be properly defended.

It is amply clear from what my noble friend has said that, if this amendment were inserted into the Bill, it would have the potential to make a material and beneficial difference to the process of discharging certain patients from a secure mental health unit in particular types of situations. As my noble friend said, and as we all know, there have been many instances where autistic patients have been detained inappropriately and for long periods under the Mental Health Act and where families have struggled to secure their relatives’ release.

I cannot see a logical reason why a mental health tribunal should not be placed on an equal legal footing with the Court of Protection in this very limited respect. I hope the Minister will agree.

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

My Lords, I am most grateful to the noble Baroness, Lady Browning, for tabling Amendment 128 and for her contribution, along with that of the noble Earl, Lord Howe.

On the proposals in Amendment 128, I can tell your Lordships that, under the current tribunal procedure rules, the tribunal can direct responsible authorities, which could be a local authority or an NHS body, to provide evidence. The practice directions that apply in mental health cases place a requirement on the responsible authority to provide reports and records relating to the patient’s detention treatment and any after-care plans. The tribunal can use these reports to decide whether the detention criteria are being met. Therefore, it appears that the tribunal has extensive powers to require responsible authorities to provide the information to support its decision on whether to discharge a patient. I hope that the noble Baroness will be satisfied with this response and will withdraw her amendment.

[Baroness Browning (Con)]

My Lords, I am grateful to my noble friend for his support from the Front Bench and to the Minister for her reply. Although it was very reassuring, could I ask her to clarify something? Has the level of information leading to a proper discharge plan under the existing powers of tribunals been set in primary legislation, which is what I am asking for under this Bill, or is it in secondary legislation or guidance?

[Baroness Merron (Lab)]

I am happy to confirm that to the noble Baroness. The important thing for me is that we make sure that, as always, we can move with best practice and keep up with what is needed. With that in mind, I will confirm that later to the noble Baroness to ensure that I am correctly answering her detailed question.

[Baroness Browning (Con)]

I am grateful to the Minister, as always. She is always helpful with these difficult points. I will just flag up that if the tribunal power to get that information in order to encourage more discharges is not in statute, then perhaps we will return to it at a later date. I beg leave to withdraw the amendment.

--- Later in debate ---

[Lord Kamall (Con)]

My Lords, I welcome the amendments from the noble Lord, Lord Bradley. As usual, he has been very sensible and measured in the amendments he has tabled. As the noble Lord reminded us, he has been very patient on many of the measures he is proposing.

I will speak to Amendment 140, which is also in the name of my noble friend Lord Howe, and hopefully touch on some of the amendments from the noble Lord, Lord Bradley. On a positive note, I will say how much we welcome Clause 46 and its removal of police stations and prisons as places of safety under the Mental Health Act. I think that noble Lords across the Committee welcome that, and the Government are to be congratulated on it.

The Wessely review stated:

“Far and away the best way to improve the care and outcomes for those with the severest mental illnesses is to provide more and better alternatives to detention”.


It also remarked that, all too often, opportunities for early intervention were missed. The report noted that this means that the first contact a patient often has is with the police, rather than with a mental health professional. I know we have discussed this and the overall involvement of police a number of times in Committee. I am sure we may come back to this on Report, but all noble Lords are aware that this must be addressed. Clause 46 is therefore very important in implementing that recommendation from the Wessely review.

I want to focus on a sentence that comes after the recommendation in the Wessely report:

“That means that, where they do not currently exist, health-based places of safety will need to be commissioned”.


I think this goes to the heart of the issue the noble Lord, Lord Bradley, was talking about—implementation but also data. Amendment 140 attempts to probe the Government. It would require the Secretary of State to publish a report on alternative places of safety for patients who are liable to be detained, particularly focusing on community care. We need to know this; as the noble Lord, Lord Bradley, said, we need the data.

Noble Lords have raised many times that we know that everything is not going to be done overnight. We understand that. We know there is a 10-year timeframe. We want a better understanding of what will be delivered when. Some of it will be subject to spending reviews, but some of it will be delivered whatever the result of a spending review. It is all very well saying that police stations and prisons and cannot be used as places of safety—no disagreement there—but this will mean that patients have to be placed elsewhere. Clause 46(2)(a) states that a place of safety for an adult is

“any hospital the managers of which are willing temporarily to receive that person”.

So far, the Bill seems to say—the Minister may correct me—that the only place of safety is a hospital. If I have misunderstood, I am prepared to be corrected, but as all noble Lords will know, that is not always ideal. Capacity in hospitals is in short supply. What will happen if a place of safety is needed but there are no appropriate hospitals nearby that are willing to receive that person, for lack of available space or staff? That is why this amendment places a focus on community-based alternatives for places of safety. If we can shift some of the burden here away from hospitals and into the community, part of the problem might be alleviated.

On an earlier amendment, Amendment 151, the noble Baroness, Lady Bennett, said that we all know that capacity in the community is currently quite limited. The report required by my amendment would enable the Secretary of State and the Department for Health and Social Care to consider and create a plan to develop greater capacity in the community for this purpose. We understand that not everything can be delivered now, but we would like to see a plan so that we can understand the Government’s intentions, their own timeframe and how they intend to roll this out. The amendment once again aims to probe the Government on their implementation plan.

I thank the Minister for meeting my noble friend Lord Howe and me to discuss appropriate places of safety. In that meeting, the Minister mentioned the community crisis houses that the noble Lord, Lord Bradley, alluded to, and said that her department was investigating how these might be used as alternatives to hospital or, indeed, police stations. As Mind says on its website, crisis houses provide

“intensive, short-term support to help manage a mental health crisis in a residential setting, rather than in a hospital”.

They can vary; some may simply provide temporary overnight accommodation to ensure that those experiencing mental health crises have a safe space away from other areas of their life, while others may provide treatment as well. Many of these crisis houses are operated by voluntary and civil society organisations.

One of my great passions in politics is to champion the role of local community civil society groups, so that we do not always have to look to the state to provide all the solutions. I think that there is some real promise here, and the Government are to be congratulated on it, for the provision of community crisis houses to be expanded, so that they can act as health-based places of safety, as the Wessely review recommended.

The questions I have at this stage for the Minister are in the nature of a probing amendment. What progress has the department made in exploring these community crisis houses and, indeed, other community-based places of safety, as alternatives to police stations and prison cells? Can the Minister tell us, when the Government are implementing the provisions of Clause 46 and commissioning health-based places of safety, whether they will include discussions with local civil society organisations and charities about how best to implement them, perhaps in partnership? I am sure she will recognise that their expertise will be highly beneficial and that they often know their local community much better than officials do, whether those be national officials or sometimes even local government officials. I appreciate that the Minister will not necessarily have all the answers tonight but, if not, I look forward not only to her comments but to the letter that she will promise to write to us afterwards.

[Baroness Merron (Lab)]

My Lords, I thank my noble friend Lord Bradley for his contribution and for Amendments 128A and 163B. I also thank the noble Lord, Lord Kamall, for speaking to Amendment 140 in his name and that of the noble Earl, Lord Howe. We are committed to implementing these reforms as soon as is it safe and practical to do so. We will return to this matter on the next day in Committee.

As I have said before—I know that noble Lords have heard this—we are reluctant to commit to enacting single provisions or publishing single plans or reports at specific times, given their dependence on so many other developments, particularly spending reviews. Removing police stations and prisons as places of safety under Section 55, and removing police stations under Sections 135, 136 and 136A will, as noble Lords suggest, require making sure that viable alternatives and clear pathways into support are fully established and in place. Commencing by regulations enables the reforms to be enacted once this is the case.

I know that my noble friend Lord Bradley is aware of this, but I will repeat it in respect of these amendments. Officials from my department, the Ministry of Justice and the Home Office are working with health and justice partners across government to develop the necessary plans to ensure that sufficient resources and the right processes are in place, and to establish clear timelines for implementation.

Mental Health Bill [HL]

Baroness Merron Excerpts

Committee stage
Monday 27th January 2025 Lords Chamber

I urge the Minister to see what can be done to ensure that the provisions of this Bill relating to the appointment and role of nominated persons can be made fully compatible with the provisions of the Children Act, and, most especially, the best interests test that that Act lays down as the iron principle governing this entire field of law.

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

My Lords, I thank noble Lords for an extremely helpful debate. I want to say how much I understand the concerns around the nominated person regarding children and parents, and the great need to get this right in the way that noble Lords have rightly unpicked today.

It is very important that parents are involved in a child or young person’s care. I say to noble Lords, as this has come up before, that we do not intend or wish to undermine the rights or responsibilities of parents. In the vast majority of cases, the nominated person for a child or young person will be their parent or whoever has parental responsibility, either because they have decided that themselves, with the relevant competence or capacity, or because they are appointed by the approved mental health professional.

For under-16s the Bill sets out that if they lack competence to make this decision, the approved mental health professional must appoint a parent, or a person or local authority with parental responsibility. The Bill aligns with the Mental Capacity Act on decision-making capability, with young people aged 16 and over considered to have the capacity to make relevant decisions. We think it is important, as I know noble Lords do, that children and young people have the right to choose a nominated person, and I understand the need to get the nominated person right. Some 67% of over 1,200 respondents to the White Paper consultation supported extending this right to under-16s.

We must have the right processes and safeguards for all patients, and additional protections for children and young people. These safeguards will cover the nomination process and the ability to overrule the nominated person or remove someone from the role if they are not acting in the patient’s best interests. The noble Baronesses, Lady Bennett and Lady Berridge, and the noble Lord, Lord Meston, have all put forward amendments to give responsibility to the tribunal or the Court of Protection in these matters. The county court already has a role in displacing the nearest relative. We believe that it has the expertise, procedural tools and legal framework to handle sensitive disputes involving external parties, such as conflicts of interest or allegations of abuse. I emphasise the word “sensitive”. I believe that the debate today has acknowledged that we are in very sensitive territory and that we need to get this right.

The noble Lord, Lord Meston, mentioned the training of judges. I can confirm that we will be working with the county court to ensure that it is aware of and can fulfil the requirements of the new provision.

The noble Baroness, Lady Berridge, asked for figures on county court applications, and I will be very glad to write to her and answer her fully. Similarly, I will be very pleased to write to her in detail on the matter of legal aid.

The Act and the Bill allow for someone who is not acting in the interests of the patient to be overruled or removed from this role. On Amendment 68 specifically, the Bill enables the responsible clinician to overrule the nominated person on the grounds included the amendment, so I am grateful for its being brought before us today. This will be quicker and will avoid burdens on the tribunal.

On Amendment 69, transferring the role of the nominated person to the Court of Protection would expand the court’s remit to under-16s. Currently, the court can deal only with the financial affairs of under-16s. The Court of Protection makes decisions for those lacking capacity, but patients need to have capacity to have appointed their own nominated person. Where they lack capacity or competence, the approved mental health professional will appoint, and the Bill sets out the grounds for them to terminate the appointment.

On Amendments 77 and 84, the noble Baroness, Lady Berridge, asked about the concept of a temporary nominated person. This is in recognition that such an appointment by an approved mental health professional is only until the person concerned has the relevant capacity or competence to choose their own—that is what is meant by the word “temporary” here.

The First-tier Tribunal (Mental Health) in England and the Mental Health Review Tribunal for Wales are focused on reviewing detention under the Mental Health Act. The provisions of the amendments would add additional burden on that tribunal. My concern is that it would risk undermining its core function and delay detention reviews, which I know is not something that noble Lords would wish.

Amendment 70, tabled by the noble and learned Baroness, Lady Butler-Sloss, would specify that parents, guardians and anyone with parental responsibility can apply to the court to displace a nominated person. The Bill already allows anyone involved in the patient’s care or welfare to apply to the county court to terminate the appointment of a nominated person. This includes parents, guardians and anyone with parental responsibility, as her amendment seeks.

On Amendments 72 and 73, in the names of the noble Earl, Lord Howe, and the noble Lord, Lord Kamall, I wholeheartedly agree that the law has to prevent exploitation and manipulation. The nomination process is indeed intended to ensure that the decision is the patient’s own. I recognise the circumstances that the noble Earl, Lord Howe, and other noble Lords described as possibilities. We have to consider all the potential scenarios, which are very real challenges to us. A health or social care professional, or an advocate, must witness the nomination and confirm in writing that the nominated person is suitable and that there has been no fraud or undue pressure. On the point the noble Earl raised, the code of practice will include guidance on how to determine this.

Amendment 76 was tabled by the noble and learned Baroness, Lady Butler-Sloss. We understand the desire to involve parents in the decision, and for the vast majority this will be appropriate. We are concerned that the amendment’s requirement to consult a parent, guardian or someone with parental responsibility could risk undermining the principle of giving children and young people a choice. It could also, in a different way, pressure the child into choosing the parent, in circumstances that might be far from desirable. Although we do not think that we should require consultation with the parents in all circumstances, we would expect the witness to discuss the nomination with parents and others with interest in the welfare of the child as part of the assessment of suitability. We will consult on guidance in the code on how practitioners should encourage the child or young person to involve their parents, even if they are not the nominated person, unless it is inappropriate.

On Amendment 82, tabled by the noble Baroness, Lady Berridge, I agree that parents and carers are to be given information about the care and treatment of their child. If a child nominates a person other than their parent as their nominated person, their parents retain legal rights under parental responsibility. These rights include the right to be consulted on certain decisions and to receive information about the child’s care. The Bill also introduces a duty on the responsible clinician to consult with people involved in the child’s welfare on care and treatment planning, which includes parents and carers.

With those comments in mind, I ask noble Lords not to press their amendments.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I thank the Minister for her careful and detailed response to an important group of amendments. It may affect only a small number of cases, but they are cases where we really need to get this right. Those two adjectives apply very well to this whole debate.

I will make a couple of comments in response. We have had three suggestions about where the applications to remove the nominated person should be. Personally, I do not have a strong view. I thought the point from the noble Baroness, Lady Berridge, about legal aid was important. Justice unfunded is justice denied, so it really is important that there is that full and necessary support, wherever they end up.

With that, I pick up the important point made by the noble Earl, Lord Howe, about the witness being such an important person to ensure that this process goes well. The noble Earl talked about making sure the guidance is right. I add that we have to make sure that the resources are there, thinking about our overstretched mental health services. We need to ensure that the person who will be the witness has the time to put in the resources to ensure that they can properly be a witness. It may not be a subject of law, but it certainly needs to be thought about.

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[Earl Howe (Con)]

My Lords, in this group of amendments my noble friend Lady Berridge has raised an armada of issues which I think it is clear to all of us cannot be ducked. These issues, as she said, were examined at length both during the independent review and by the Joint Committee, but it has to be said that in both instances it proved too much of a challenge to identify a satisfactory resolution to them. For that reason, as we observed in our debate on the previous group, the weight of these matters now rests on the shoulders of this Committee and of the Government.

In summary, we need arrangements that are robust enough to ensure that a nominated person’s appointment can be effectively challenged, and that, in certain circumstances, where necessary, the exercise of their powers can be legally contested and blocked. Without those measures, we shall leave an unacceptable lacuna in the law and, more pertinently, run a high risk of exposing children to personal danger.

My noble friend is to be thanked for assisting this Committee’s deliberations with the clear way in which she has set out the challenge, and I hope and trust that the Minister will wish to grip the challenge with her usual vigour.

[Baroness Merron (Lab)]

My Lords, like the noble Earl, Lord Howe, I am most grateful to the noble Baroness, Lady Berridge, for introducing an appropriately wide range of scenarios, questions and testing. That is important for the Committee but also for our ongoing work. As the noble Baroness, Lady Tyler, said, to describe this area as complex is to use too small a word, and I think we are all wrestling with that to get it in the right place. I know that noble Lords are aware that the work is ongoing, and I thank them for their engagement and interest in this issue. As I said previously, I very much understand the need for a robust process to keep children and young people safe and ensure that only appropriate individuals can take on the role of nominated person, while giving children and young people that right to choose.

I will respond collectively to the amendments put forward in this group. As I set out earlier, we agree that in the vast majority of cases there is an expectation that a parent or whoever has parental responsibility would take on this role, and that would include consideration of special guardians and child arrangement orders. We also agree that, where parental responsibility has been removed due to care proceedings, in the vast majority of cases it is unlikely to be appropriate for such a person to take up this role. My reference to this being a complicated area—

[Baroness Berridge (Con)]

My Lords—

[Baroness Merron (Lab)]

Perhaps the noble Baroness will let me make a bit of progress.

[Baroness Berridge (Con)]

I think I need to clarify a point of law—I am looking to the noble Lord, Lord Meston. In care proceedings, is parental responsibility removed? I do not believe it is; it remains with the parents. That is very important.

[Baroness Butler-Sloss (CB)]

It is shared.

[Baroness Merron (Lab)]

I thank noble Lords for that exchange, which brings me to my repeated point about the complicated area in which we are treading.

As was highlighted by the pre-legislative scrutiny committee, we will set out our expectations in the code of practice as to whom approved mental health professionals would appoint, or the witness would confirm suitability of, in a range of circumstances, including in the more and most complex cases. We will consult on this to ensure that we cover as many scenarios as we can.

I can confirm to the noble Baroness, Lady Berridge, that we are working with NHS England, the Department for Education, the Association of Directors of Children’s Services and others to ensure that our policy and guidance reflect what can be a very complex arrangement for some children under the Children Act.

The Bill is clear that where an approved mental health professional is appointing a nominated person for an under-16 they must appoint someone who has parental responsibility, and the amendments extend this approach to all under-18s. As I said previously, we are allowing more flexibility for 16 and 17 year-olds rather than prescribing in legislation who this must be.

While the amendments put forward a wide range of circumstances, we all know—and the noble Baroness, Lady Berridge, demonstrated this—that there will be nuanced and complex cases, especially for 16 and 17 year-olds. Someone outside the proposed list, such as a step-parent, may be the most appropriate person, or a kinship care arrangement may be in place. These amendments propose regulatory powers in recognition of this but we feel that updating statutory guidance will allow us to keep this up to date and in review as new policy is implemented.

The noble Baroness, Lady Berridge, asked about differences between special guardian orders and special care orders. The Bill says that the approved mental health professional must appoint the local authority or anyone else with parental responsibility as the nominated person. The special guardian, as someone with parental responsibility, would be appointed if a special guardianship order was in place. In relation to the proposal for two people to take on this role, as the nominated person exercises specific statutory functions under the Mental Health Act, we feel it is right that only one person has these limited powers, to avoid the potential for disagreement and confusion about who can exercise the relevant power.

We recognise that there will usually be more than one person with parental responsibility and that the approved mental health professional will need to determine who should be the nominated person. Under the current system, this would be the older parent, which we do not think is necessarily appropriate. We will provide guidance for approved mental health professionals in the code of practice. This may include which of the parents is recorded as the child’s next of kin, who the child lives with and who is accompanying the child.

The noble Baroness, Lady Tyler, helpfully inquired about the status of the nominated persons paper that was sent out in an attempt to be helpful. It was developed very much to support the debate, which it certainly has done, and we intend to develop it further. I very much welcome the further engagement from Peers and we will continue to formally consult as part of the code of practice so that it is an aid to the considerations of noble Lords. I hope it is doing that.

In the current nearest relative provision, only one parent will hold this role. As I mentioned in the previous debate, this will not exclude the other parent from being involved in their child’s care. Whether or not they are the nominated person, parents and carers should be given information about the care and treatment of their child, unless it is inappropriate. This is reflected in the Bill. We absolutely agree that someone should be removed as the nominated person if they are not acting in the interest of the patient. Criteria are included in the Bill for when an approved mental health professional may terminate an appointment, one of which is when the person is

“otherwise not a suitable person to act as a nominated person”.

On the points made by a number of noble Lords, suitability includes whether there is any risk to the patient. This may include if the person is behaving in a way that indicates they are unsuitable for the role; for example, if they are exercising their powers without due regard to the welfare of the person.

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[Baroness Browning (Con)]

Reflecting on what the Minister has just said, would that close the Bournewood gap, which we tried to close in earlier legislation, where a professional carer cared for an autistic man who was not able to articulate for himself, but was overruled by the clinician? I am just trying to get my head round what she has just said because that was the Bournewood gap and, as the Minister will know, it ended up in the European Court before it was resolved.

[Baroness Merron (Lab)]

We need to be considering that as one of the scenarios and I would certainly be very glad to give the noble Baroness and noble Lords a more considered response to the very important point that has just been raised.

Under this policy, an approved mental health professional would terminate their appointment if the nominated person is not acting in line with the patient’s interests. I really wish to emphasise this.

For all these reasons and the responses I have given, I hope that the noble Baroness will feel able to withdraw her amendment.

[Baroness Berridge (Con)]

My Lords, I am grateful to noble Lords who have spoken and for the considered nature of the response and the clarification regarding the special guardianship. However, as we have outlined, other people remain having parental responsibility and it seems that under the Bill, as it is only one person, it could be that the residual person still has parental responsibility. It could just be that person under the Bill and not, in that situation, who is appointed.

I am concerned, not only by the outline at the beginning in relation to parental responsibility being removed. I just feel that there is a lack of understanding—with all due respect to the Minister’s diligence, thoroughness and engagement with colleagues—about the depth of the issue that we have here. She mentioned “would” appoint. That seems something that can be under the Mental Health Act code—“would” seems to be that as long as you document your reasons for that, you can move. It seems that from the situation I have outlined, in which the 16 or 17 year-old has been removed from the dad’s care because he has been shown to be, and proven by the family court to be, a danger, he could be appointed as the nominated person. Then we are relying on a speedy process in the county court—which we are not sure we always get legal aid for—to remove him. I am concerned by phrases such as “more flexibility for 16 and 17 year-olds”. Does that include the 16 and 17 year-olds who are under special guardianship or where there is a care order?

It seems that there is a conflict, based on what the co-leader of the AMHPs is saying, what the review has said and what the response says. We have a conflict between two pieces of legislation that we must continue to grapple with. On phrases such as “working with the DfE”, I asked specifically whether there had been a meeting with the Minister for Children and Families. The responsibility for a serious case review sits with that department. If we are to some extent right, this risk to children will manifest itself in an imperfect system. Obviously, there are professionals and clinicians, but we all know of cases that have gone wrong and ended up in inquiries.

I remain concerned by the lack of clarification on legal advice. Legally, in some ways this is fascinating—but it is not fascinating because it involves child protection. I welcome the engagement and I am sure that we will meet again in regard to this, but the severity of the risks that we are exposing, and allowing young people and AMHPs to go behind findings of fact in the family courts made under the Children Act is an incredibly serious issue. I hope that the Minister will be furnished with that kind of geeky legal advice, because for the children’s sake we need that.

However, I am grateful for the manner of her engagement and of course beg leave to withdraw the amendment.

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Moved by

[Baroness Merron]

87: Clause 31, page 42, line 37, leave out paragraph (a)
Member’s explanatory statement
This amendment, my other amendments to Clause 31 and my new clause inserted after Clause 31 would provide for commencement two months after Royal Assent of provisions about tribunal reviews concerning patients subject to conditions amounting to a deprivation of liberty.

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Moved by

[Baroness Merron]

94: After Clause 31, insert the following new Clause—
“References: restricted patients not subject to deprivation of liberty conditions(1) The Mental Health Act 1983 is amended as follows.(2) In section 71 (references by Secretary of State concerning restricted patients), for subsection (2) substitute—“(2) The Secretary of State must refer to the appropriate tribunal the case of any restricted patient detained in a hospital if—(a) the patient’s case has not been considered by the appropriate tribunal within the last 12 months, whether on the patient’s own application or otherwise, and(b) there is no pending application or reference to the appropriate tribunal in relation to the patient’s case.” (3) In section 75 (applications and references concerning conditionally discharged restricted patients)—(a) before subsection (2C) (as inserted bysection 31(3)(a)of this Act) insert—“(2B) Where a restricted patient has been conditionally discharged, is not subject to conditions amounting to a deprivation of liberty and has not been recalled to hospital, the Secretary of State must refer the patient’s case to the appropriate tribunal on the expiry of—(a) the period of two years beginning—(i) in the case of a patient who has previously been subject to conditions amounting to a deprivation of liberty, with the date on which the patient most recently ceased to be subject to such conditions, and(ii) in any other case, with the date on which the patient was conditionally discharged, and(b) each subsequent period of four years.”;(b) in subsection (2D), after “subsection” insert “(2B) or”;(c) in subsection (2E) omit “, is subject to conditions amounting to a deprivation of liberty”;(d) in subsection (2F), after “subsection” insert “(2B),”;(e) in subsection (2H), after “subsection” insert “(2B),”;(f) in subsection (3), after “subsection”, in the second place it occurs, insert “(2B),”.(4) The amendments made by this section apply in relation to any person who is a restricted patient within the meaning given by subsection (1) of section 79 of the Mental Health Act 1983, or is treated as a restricted patient as a result of that subsection, whether the person became such a patient (or treated as such a patient) before or after the coming into force of this section.”Member’s explanatory statement
See the explanatory statement for my amendment to Clause 31, page 42, line 37.

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[Baroness Merron (Lab)]

My Lords, I thank all noble Lords for their amendments and considerations, including the noble Baroness, Lady Barker, for her observations on the group before us.

On Amendment 99, tabled by the noble Lord, Lord Kamall, services already capture data on instances of police using relevant powers to take patients to emergency departments. The Home Office collects national policing data on detentions under Section 136 of the Act and removal to a place of safety, including the number of times that A&E has been used. NHS England’s emergency care dataset includes data on mental health, including how patients are referred to hospital and their conveyance methods. I understand the points that the noble Lord was seeking to probe, but we feel that it is not necessary to create a new legislative requirement.

My response to Amendment 137, also tabled by the noble Lord, Lord Kamall, will focus on the position in England, because I imagine that that is what the noble Lord is particularly interested in, and of course different arrangements apply in Wales. We recognise the importance of preventing illegal drug use in mental health units and take the issue extremely seriously. All units must have robust policies in place to prevent the introduction of illegal drugs. To pick up the point that the noble Lord put to me about the recording of drug-related incidents, I assure him that such incidents would be recorded as a patient safety incident. While published data does not break down the nature of an incident to get an aggregate view at national level, details of incidents will nevertheless be shared with NHSE and the CQC to allow appropriate action then to be taken.

As I have referred to, providers must inform the CQC of certain events affecting their services. Inspectors review all reported concerns, as I have said, and that is important to determine the necessary follow-up actions. Issues that relate to the introduction and use of illegal drugs in an in-patient setting would be reflected in the CQC’s regulatory inspection findings where concerns have been identified, with potential consequences for ratings and for regulatory sanctions. We believe that there are already processes in place for the CQC in England to receive information about drug-related incidents. We feel that this is a better use of the capacity—which is not infinite, as the noble Lord knows—of the regulator, rather than having a national report on the overall efficacy of the systems that are in place.

Amendment 151 was tabled by the noble Baroness, Lady Bennett of Manor Castle, and spoken to by a number of noble Lords, and I am grateful for their input. A number of other amendments have called for statutory reports on current community services. As I have said previously in response to those debates, we recognise that reducing detentions cannot be achieved by legislation alone, and will absolutely depend on the right services in the community. The CQC publishes an annual survey on community mental health support, and we will be publishing a 10-year plan for the NHS later this year. Progress in community mental health services is already being made. In the last 12 months, more than 400,000 adults have received help through new models of care, which aim to give people with severe mental illness greater choice and control over their care. However, we recognise that more needs to be done.

I want to pick out a particular focus on innovation in this amendment. The noble Baroness, Lady Bennett, referred to the fact that the impact assessment does not include costs for community services. That is not quite the case. There are significant costs associated with the changes to learning disability and autism, which are included in the impact assessment. I agree that wider reforms in community mental health services are needed for the reforms to achieve their intended benefits in full, but they are not a direct consequence of this Bill. That is why they are not costed in the impact assessment. I hope that will be a useful clarification for the noble Baroness.

As I mentioned last Monday, NHS England is already piloting the 24/7 neighbourhood mental health centre model in England, building on learning from international exemplars, some of which have been brought to the attention of your Lordships’ House by various noble Lords, and I have welcomed that. Six early implementers are bringing together their community crisis and in-patient functions into one open-access neighbourhood team that is available 24 hours a day, seven days a week. That means that people with mental health needs can walk in, or self-refer, as can their loved ones or concerned professionals. We are currently commissioning an evaluation of these welcome pilots, which is due to report in June 2026.

The noble Baroness, Lady Bennett, referred to reports last week of an increase in the number of young people admitted to general hospital wards with mental health concerns. NHS England is in the process of developing a new model for specialised children’s and young people’s mental health services, supported by a new service specification and quality standards. That new model would support the delivery of specialist services in the community and in-patient settings to ensure that children and young people are treated in age-appropriate in-patient environments, as well as the least restrictive environment close to the child’s or young person’s family and home. The noble Baroness’s point is well made, and I hope that will be helpful.

[Baroness Bennett of Manor Castle (GP)]

I welcome what the Minister has said about the pilots and the significant changes being made to existing mental health services. Short of someone putting down an Oral Question or securing a debate, how will Parliament be able to monitor that? We know that, in the health service and more broadly, successful pilots happen but then disappear without trace and never get implemented. How will Parliament be able to assess progress from the pilot stage to implementation, along with broader changes? What mechanisms are there?

[Baroness Merron (Lab)]

The noble Baroness makes a fair point, and that is something I shall return to later in Committee. I am keen, as I hope noble Lords know, to speak in your Lordships’ House about progress that is and is not made, and I will continue to do that.

Overall on this group, given the amount of plans and reporting already in place, we do not think that additional statutory review, particularly in relation to Amendment 151, is necessary. For all the reasons that I have put to the Committee, I hope noble Lords will be good enough not to press their amendments.

[Lord Kamall (Con)]

My Lords, I thank the Minister for her response and thank all noble Lords for their contributions to this group. I should have also mentioned that I am very sympathetic to the intention behind Amendment 151 from the noble Baroness, Lady Bennett. Noble Lords throughout this debate have been speaking about community resources and accountability for those resources; indeed, I have a related amendment in the seventh group. In some ways, the Minister has partly answered that probing amendment.

I am grateful to the noble Baroness, Lady Barker, and will reflect on the points she made. As the noble Baroness, Lady Tyler, said previously, this was a probing amendment to see what data was being collected. Noble Lords will understand that, if we want to improve a situation, we need to collect data. It may not be perfect, and perhaps we can have some conversations between now and Report about that. I am very grateful that the Minister said that this data is collected. I wonder if she could write to us with links to where it can be found. That could address some of the concerns raised by stakeholders who wrote to us, which led to this amendment being tabled.

I remember that, when I read the work of the pre-legislative scrutiny committee, the Metropolitan Police service’s submission said that, in 2021, for the first time more patients were conveyed to a health setting in a police vehicle than in an ambulance. I wonder if that is still true or if that situation has been reversed. The purpose of these amendments was to seek what data was available, so that we can address the problems that Amendment 99 and 137 sought to address. With those comments, I beg leave to withdraw the amendment.

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[Baroness Butler-Sloss (CB)]

In the absence of the noble Baroness, Lady Murphy, I will just say that I support all these amendments. I expressed concern about under-16s and those aged 16-18, but that does not stop me thinking that these advance choice documents are an excellent plan. However, I am concerned about the point that the noble Baroness makes with Amendment 120. An independent mental health advocate would be extremely helpful, because there may be quite a lot of people who really would not know how to make an advance choice document, would be very concerned about it and might write down some really not very sensible things, when they could have help as to what they really wanted. I strongly support the noble Baroness’s amendment.

[Baroness Merron (Lab)]

My Lords, I am grateful for all the contributions in this group. I will start with Amendment 115, tabled by the noble Earl, Lord Howe, and supported by the noble Lord, Lord Kamall. Under the Bill, services should not only offer individuals who are likely to benefit from making an ACD information and support to do so, they should proactively support such individuals. This is functionally equivalent to a right to request an advance choice document.

The amendment applies to large groups. We have concerns that, for example, it may be practically challenging or sometimes inappropriate to contact people who were detained some time ago. We intend to identify groups in the code of practice that services should target; it can then be updated in response to changing best practice and emerging research.

On the point raised by the noble Earl, Lord Howe, and referred to by the noble Lord, Lord Stevens, and the noble Baroness, Lady Browning, about how advance choice document information is made available to patients, we will set out in the code of practice detailed guidance on how services should discharge their duties under the Bill to inform and support individuals to make an ACD. Any failure to implement the duty in this aspect of the code could ultimately be challenged in the courts. I hope that gives some indication of the strength of that provision in the Bill.

The noble Lord, Lord Stevens, raised the implementation timeline, as outlined in the impact assessment. We want to ensure that there is appropriate resource in the system before ACDs can be brought in. I am sure noble Lords understand that this is critical, for ACDs to have the right level of impact. For example, the effect of ACDs is dependent on the expansion of the second opinion appointed doctor service. In the meantime, services can, of course, progress with putting ACDs that deal with patient needs and wishes overall should they become detained. That would very much build on the work that South London and Maudsley, and others, have done.

I turn to Amendments 117 and 125 in the name of the noble Baroness, Lady Barker. I confirm that we are committed to mitigating the barriers that get in the way of creating an advance choice document. The code will make it clear that commissioners should provide accessible information in response to individual needs, with flexibility around how individuals make their preferences known—the point that the noble Baroness raised. We plan to create a standard advance choice document template for people to complete, with supporting guidance. That should prompt thoughts about the things that an individual may wish to consider and decide before they become unwell. I can assure noble Lords that the template will be available digitally as well as in hard copy. Our intention is that a digital version of the document will be created for easy access by professionals as needed.

Amendment 120, tabled by the noble Baroness, Lady Murphy, and spoken to by the noble and learned Baroness, Lady Butler-Sloss, has the stated intention that mental health in-patients create an ACD. While the Bill does not prevent this, in most cases it will not be the best time, as patients may be very unwell and lack capacity. Insights from the South London and Maudsley NHS Foundation Trust with King’s College London suggest that encouraging people to create an advance choice document after discharge—when their health has improved and the support network can help—can be useful. The person’s community mental health team is best placed to provide support, rather than an independent mental health advocate whose role is to support people who are detained. The duty on commissioners in the Bill is intended to focus on the community and other contexts outside of hospital. We feel that this is more likely to increase the uptake of advance choice documents.

[Baroness Barker (LD)]

The crucial question that the noble Baroness is asking is around which staff can access this information and where. That means that the information in the ACD has to be always available to whoever is seeing the patient, wherever they happen to be. Does that mean that, as in palliative care, the ACD will become part of an electronic patient record, and that there will be an expectation that all practitioners, wherever they are, will refer to it all the time?

[Baroness Merron (Lab)]

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

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

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

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

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

[Lord Scriven (LD)]

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

[Baroness Merron (Lab)]

I would be very glad to share the date if I could put a date on it. It will be after Royal Assent, and I will keep noble Lords updated.

[Earl Howe (Con)]

My Lords, I very much appreciate the support from around the Committee for my Amendment 115. I support all the other amendments in this group, each of which is designed to bolster the rigour and thoroughness of the advance choice document process.

It is good to hear from the Minister that the code of practice will include guidance on how information on ACDs will be made known to relevant would-be patients. I shall need to reflect on this, but I confess I retain a worry in this area. The CQC in its annual report of 2020-21 on monitoring the Mental Health Act reported that many patients do not have their rights explained to them during their treatment. This is despite the existing requirement in the Mental Health Act code of practice for hospital managers to provide information both orally and in writing. Clearly, if someone without an existing ACD is admitted to a mental health unit for treatment, it will be too late for them to execute a valid ACD during that episode of care. The time to be informed that an ACD could be an appropriate thing for them to draw up is once they are discharged, to cater for possible future contingencies.

I suggest that the CQCs finding is still relevant, its point being that the NHS is not all that good at providing information to patients in a timely or appropriate way. Therefore, I think that creating a duty to do so would add value—perhaps not in the precise terms I have used in the amendment, but in similar language. That could, incidentally, be achieved quite easily if mental health patients were automatically invited to complete a debriefing report following discharge from hospital in the way that I suggested in an earlier amendment.

The prize, let us remember, could be significant. I refer noble Lords back to remarks by the noble Baroness, Lady Murphy, in an earlier debate, where she indicated that independent advocates have been proved as central to the success of advance choice documents—a facilitator, in other words. She referred to a study in North Carolina that showed that providing a facilitator in the form of an independent advocate increased the number of people making a psychiatric advance directive from 3% to 60%. That is a very powerful set of figures.

I hope the Minister will be open to further discussion on this and the other amendments in the group between now and Report. Meanwhile, I beg leave to withdraw my Amendment 115.

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Moved by

[Baroness Merron]

127: Clause 43, page 55, line 35, after “provided” insert “or arranged”
Member's explanatory statement
See the explanatory statement for my amendment to Clause 4, page 5, line 20.

Mental Health Bill [HL]

Baroness Merron Excerpts

Committee stage
Wednesday 22nd January 2025 Lords Chamber

[Lord Stevens of Birmingham (CB)]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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[Baroness Merron (Lab)]

I would be very pleased to look into it further, but, as I have described, this is a rolling programme. I emphasise that the CQC has that duty both to monitor but also to make the relevant bodies subject to sanctions if needed—in other words, more immediately. So I am concerned that through this amendment we could be creating a structure which is actually less flexible and responsive than the one we have now.

Amendment 148, tabled by the noble Lord, Lord Crisp, and the noble Baroness, Lady Hollins, would impose on integrated care boards—ICBs—a legally binding duty to provide local, in-person, specialist withdrawal treatments for patients on psychiatric medication prescribed during the course of their treatment by services under the Mental Health Act. In addition, there would be a duty on each ICB to send to the Secretary of State an annual report on the availability, uptake and outcomes of this support. Under this amendment, the Secretary of State would be obliged to lay these reports before Parliament. ICBs would also be subject to a requirement to provide a 24-hour helpline and online platform to support patients to receive withdrawal treatment.

Let me say at the outset that I recognise the difficulties that withdrawal can pose. I recall that the noble Lord, Lord Crisp, spoke on this very point in the Chamber last month and was also good enough to speak directly to me. It is, I agree, an issue that will not go away and, per the noble Lord’s request, I would be happy to arrange a meeting. I feel there is a whole area here to which we today, considering amendments, cannot do justice, so I would be pleased to do that. To the noble Lord, Lord Mawson, who has tabled Written Questions, I say that I look forward to answering them, and I hope that he will look forward to reading my Answers.

Where relevant, we would expect the patient’s statutory care and treatment plan to include a tapering plan and put in place whatever additional support is needed to enable a patient’s recovery and effective discharge. On the requirement to provide support in the community and report on availability, this is the responsibility of local health commissioners. In 2023, NHSE published a framework for ICBs and primary care boards on how to optimise personalised care for patients prescribed medicines associated with dependence or withdrawal symptoms. With regard to the requirement in the amendment for a 24-hour helpline, this would not seem proportionate, given the relatively low numbers of people who might need this service, who should already have a support plan in place, including access to relevant local support services.

Finally, Amendment 154, tabled by the noble Baroness, Lady Bennett, would allow the Secretary of State to make regulations giving people detained in hospital and those subject to community treatment or guardianship orders the ability to have certain care and treatment matters considered by a mental health tribunal.

This is a very complex area, as I am sure the noble Baroness is aware. The amendment seems to draw on the recommendation made by the independent review to give patients a new right of appeal to a single judge of the mental health tribunal regarding compulsory treatment. I recall that the previous Government publicly consulted on this new right, and the majority of respondents raised major concerns in this regard. The consultation was followed by further long and careful consideration with stakeholders, which led the then Government to the conclusion that this safeguard is just not viable. A solution could not be found that provided an efficient and effective route of appeal for patients while avoiding the risks of the tribunal intervening in clinical decision-making, alongside significant resource burdens. Many of these concerns were reflected in the report of the pre-legislative scrutiny committee, which also acknowledged the complexity of the issue.

We believe that the other provisions in the Bill will better achieve the same objectives of providing patient choice and autonomy, so while we do not support introducing a new role for the tribunal, I assure your Lordships that the emphasis on therapeutic benefit within the detention criteria will mean that whether care and treatment are proving effective will play a role in the tribunal’s consideration of whether or not detention should continue to be upheld. With these explanations, I hope that the noble Earl feels able to withdraw his amendment.

[Earl Howe (Con)]

My Lords, I am very grateful to all noble Lords who have contributed to this debate in such compelling ways, and I think we can see that when it comes to the experiences of children and young people in mental health units, we are dealing with a story that is a lot more substantial than mere anecdote. From briefing I have received, I am afraid I have been left in no doubt that the therapeutic environment in a number of mental health hospitals around the country—not all, of course—is, to put it mildly, a lot less than optimal.

Clearly, it is unacceptable for any patient, of whatever age, to be detained compulsorily without being offered treatment. It is unacceptable that drugs or restraint should be used as punishments. Challenging behaviour can be difficult to deal with, but staff should be trained to deal with it in a way that demonstrates that they understand the root causes of the behaviour. Those causes can be extremely complex.

To pick up another strand of the debate, I am in no doubt that medication has a place in mental health therapy. It can often be the treatment of choice. It is one tool in the toolbox. However, I very much agree with what the noble Lord, Lord Crisp, and the noble Baroness, Lady Tyler, had to say about social prescribing. It can not only be clinically effective but save costs if it is delivered, for example, by local charities that work in the fields of music, drama or art. Incidentally, it can help budding musicians, actors and artists in their downtime to train as music, art or drama therapists, which is an added bonus.

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[Earl Howe (Con)]

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

[Baroness Merron (Lab)]

My Lords, I thank all noble Lords for examining the important issues that have been raised in this group of amendments.

Amendment 55, in the name of the noble Baroness, Lady Tyler, supported by the noble Lord, Lord Scriven, seeks to change the Mental Capacity Act to allow young people aged 16 or 17 the ability to make a binding advance decision to refuse medical treatment for mental disorder. I shall set out some concerns about the amendment that may be helpful.

First, the amendment would mean that a young person who is not detained under the Mental Health Act could refuse a mental health treatment, even if it was life-sustaining. While the Mental Health Act and the Bill currently provide safeguards that enable a person’s advance decision to be overruled, detention under the Act may not always be appropriate. For example, if a 16 year-old is left very unwell following an attempted suicide, then currently they may be given treatment on the basis of what is in their best interests, under the Mental Capacity Act, if they lack capacity to consent at the time. However, under the amendment, if the 16 year-old had made an advance decision to refuse treatment necessary for their recovery or to sustain their life, then they might need to be detained under the Mental Health Act simply so that their advance decision could be overruled. This is important in terms of timely access to treatment and to avoid loss of life, of course.

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[Baroness Merron (Lab)]

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

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

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

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

[Lord Scriven (LD)]

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

[Baroness Merron (Lab)]

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

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

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

[Baroness Butler-Sloss (CB)]

The trouble with Gillick is that it does not provide, for those who have to make the decision, how to do it.

[Baroness Merron (Lab)]

I appreciate the point that the noble and learned Baroness has made. As I said, I know there are competing views about its application. I reiterate the observation that it is the current established framework, but I hear what she is saying about what she believes are the implications of that.

[Baroness Berridge (Con)]

The Minister’s own policy document says that this test should be in the code of practice. How does that not also contribute to the undermining of Gillick that the Minister refers to?

[Baroness Merron (Lab)]

Actually, my feeling about the code of practice is something that I wanted to bring up, because it has come up quite a lot. The code of practice is statutory and aimed at practitioners, and it allows nuance and so on, but Gillick is in case law and it guides us throughout. The point I am trying to make is that if it is changed in respect of this Mental Health Bill then that has implications across the wider question of competency for younger people, and that is of great concern.

[Baroness Butler-Sloss (CB)]

I apologise for interrupting the noble Baroness again, but the fact is—I speak as a former lawyer and judge who applied Gillick—it does not actually give guidance. All it says, as I understand it, is that under-16s have to be listened to. That is great, and I totally agree. What it does not do—but the amendment of the noble Lord, Lord Meston, would—is set out the guidance that those who make the decisions need to have.

[Baroness Merron (Lab)]

Obviously, I am listening closely to the noble and learned Baroness’s experience and feeling on the matter, and I will certainly be pleased to reflect on the points that she and the noble Baroness, Lady Berridge, have made.

If I continue, that may be of some assistance—we will see. It is of concern to me that the possible creation of two different tests will potentially cause further confusion and uncertainty on the ground. We are therefore not in a position to welcome a statutory test of competence in the Mental Health Act.

Before I continue to Amendment 147, I will come back to the good question raised by the noble Lord, Lord Scriven, about the legal status of clinical checklists. Because they are in the Bill, they are a statutory requirement for clinicians, to be followed in respect of all patients. I hope that will be useful.

[Lord Scriven (LD)]

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

[Baroness Merron (Lab)]

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

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

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

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

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[Lord Meston (CB)]

My Lords, I do not want to prolong this, but I have to say that, although I am disappointed and a little surprised by the response from the Government, the intention is to align the Mental Capacity Act and Gillick. It is frankly not correct, if I understand the situation, to say that it is not based on case law. I referred to a specific case in which the judge formulated, essentially, the test that appears in my amendment. As I say, I do not want to prolong this but, if necessary, I can refer the Government to that case.

[Baroness Merron (Lab)]

Perhaps I can just say to the noble Lord that, when I reflect on the discussions on this group, as well as all the others, it may be helpful to discuss this further.

Amendment 55 withdrawn.

Mental Health Bill [HL]

Baroness Merron Excerpts

Committee stage
Wednesday 22nd January 2025 Lords Chamber

[Baroness Berridge (Con)]

My Lords, I add my support for Amendment 58, tabled by the noble Baroness, Lady Watkins, and to which I have added my name. Briefly, given the time, the care and treatment plan is a major plank, a pivotal safeguard of the Bill. The safeguard is not open to voluntary patients. As the noble Baroness outlined, we want to encourage many young people to voluntarily enter a hospital to get the treatment that they need. A 2021 UCL research project found that only 23.6% of young people were detained involuntarily. The large cohort would be those who have consented by parental consent and those who voluntarily entered the treatment. As such a high proportion of the under-18 population are entering voluntarily, it is imperative that they also have a care and treatment plan.

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

My Lords, I thank noble Lords for the pertinent points that they have made.

I will start with Amendments 57 and 58. There is no doubt that all patients who are in a mental health hospital for care and treatment should have a care plan, whether or not they have been detained under the Act. This is already set out in guidance for commissioners and in the NHS England service specification and care standards for children’s and young people’s services. In line with the independent review’s findings and recommendations, care and treatment plans for involuntary or detained patients are statutory. This is because such patients are subject to restrictions and compulsory orders, including compulsory treatment, which places them in a uniquely vulnerable position.

Rather than bringing voluntary patients into the scope of this clause, we feel it is more appropriate to use the Mental Health Act’s code of practice to embed high standards of care planning for all patients—voluntary and involuntary. Specifically with regard to children and young people, any provisions that are relevant to voluntary patients are already met by existing specialist care planning standards and the NHS England national service specification for children’s and young people’s services, which providers are contractually obliged to follow. NHS England is already in the process of strengthening that current service specification.

Regarding points raised by the noble Lord, Lord Kamall, and my noble friend Lord Davies on the contents of the care and treatment plan and patient discharge plan, as my noble friend Lord Davies kindly set out for me, which I appreciate, the Government have consulted on the required contents of the care and treatment plan, as originally proposed by the independent review. The expected contents of the plan are described in the delegated powers memorandum, which has been published online. I understand the points that my noble friend made; we will return to them regarding what we intend to include in the patient discharge plan.

I turn to Amendment 59, tabled by my noble friend Lord Davies and supported by the noble Baronesses, Lady Tyler and Lady Neuberger. The plan needs to include details of interventions aimed at minimising financial harm to the patient where this is relevant to their mental health recovery. My noble friend asked for my agreement on this point. I hope that he will take that in this way. We intend to set out in regulations, rather than in primary legislation, what that plan must include. We will consider personal financial matters that are relevant to a number of the elements that we intend to require in regulations, such as the services that a patient might need post discharge. My noble friend’s point, and that of the noble Baronesses, is very well made and is taken on board.

Turning to Amendment 60A, tabled by the noble Baroness, Lady Barker, I confirm that the Bill sets out who is responsible for the statutory plan. For in-patients, this is the clinician who is responsible overall for the patient’s case. The quality of plans for detained patients is monitored by the CQC. Any housing, accommodation or wider social care needs that are relevant to the patient’s mental health recovery are already captured within the scope of the statutory care and treatment plan. We intend to require in regulations about the content of the plan that a discharge plan is a required element of the overall care and treatment plan—which noble Lords rightly have pressed the need for. Existing statutory guidance on discharge sets out that a discharge plan should cover how a patient’s housing needs will be met when they return to the community. Currently, where a mental health in-patient may benefit from support with housing issues, NHS England guidance sets out that this should be offered, making links with relevant local services as part of early and effective discharge planning.

Where a person is receiving housing benefit or their housing is paid for via universal credit, there are provisions already in place that allow them to be temporarily absent from their property for a limited duration. We know that the vast majority of people entering hospital will return home before the time limit expires, therefore avoiding a negative impact on their living situation.

We intend to use the code of practice to clearly set out expectations on mental health staff around care planning, including consideration of accommodation and housing needs, and also to highlight existing provisions that protect a person’s living arrangements while they are in hospital.

On Amendment 61, tabled by the noble and learned Baroness, Lady Butler-Sloss, we of course recognise the importance of involving parents, guardians and those with parental responsibility in decisions around care and treatment. We have already provided for this in the clause by stating

“any … person who cares for the relevant patient or is interested in the relevant patient’s welfare”.

The clause seeks to include also carers and other family. As I said last week, this is consistent with existing established terminology used in the Mental Capacity Act and the Care Act.

The amendment would also make this a requirement for all patients, not just children and young people. We do not think it is appropriate here to give an automatic right to parents to be involved in an adult patient’s care. However, we have made provisions to ensure that anyone named by an adult patient, including parents, are consulted where the patient wishes them to be.

[Baroness Browning (Con)]

On that last point about adults, I realise this is a more difficult area, but we have debated in this House reports from the charity Mind about adults, and young adults at that, who, when they have been admitted not just to mental health hospitals but to general hospitals and have had difficulty communicating —I go back to autism, but it might not be uniquely autism—hospital staff have said, “They are over 18, so we’re not listening to you, mum”, while standing by the bedside asking why a person is not eating, when there is probably a very good reason why not. We have recorded deaths of young adults because the parents of people over 18 have not been listened to. It is a mantra that I have heard many times, in many situations: “They’re over 18, it’s up to them”, when, in fact, quite clearly, their lives could be saved, or their health improved, if hospital staff had listened to mum or dad at the bedside. That is on the record and we have debated it in the past, so I wonder how the Minister thinks we can resolve it as far as mental health patients are concerned.

[Baroness Merron (Lab)]

The noble Baroness is right to raise that point. This is the difference between legislation and practice, and we have to bridge that gap. We are very alive to the point she makes, but the important point about this amendment is that we are trying to include all those whom the patient wants to be involved, not just restricting it to parents. I take the point she has made and will, of course, ensure that we attend to that. I would say that that is, as I say, more a case of how things are implemented.

On Amendment 62, in the name of the noble Baroness, Lady Tyler, and the noble Lord, Lord Scriven, it is important that the transition of a young person to adult services is planned and managed with the utmost care by the clinical team. This is reflected in existing care standards and guidelines, which set out what should be met, what relevant teams should meet and how to provide specific support where a young person’s care is being transferred to adult services. This should take place six months prior to the patient turning 18 years of age. On reviewing the patient’s statutory care and treatment plan when they reach adulthood, in Clause 20, subsection (5)(d) of new Section 130ZA already sets out that that plan must be reviewed following any change in circumstances or conditions. We think that turning 18 and transitioning from children and young people’s services to adult is a significant change and absolutely requires review of the plan. We will make this explicit in the code of practice.

Finally, I turn to Amendment 64. I thank my noble friend Lady Keeley for sharing the reality of how this manifests itself by sharing with us individual circumstances. I also thank the noble Lord, Lord Young, whose work on young carers is well known and respected. We support the intention to ensure that children are properly safeguarded. If a person is known to services, immediate safeguarding needs to form part of the planning by approved mental health professionals on behalf of the local authority and others involved in the Mental Health Act assessment before bringing a person into hospital. If a person is not known to known to services, the professionals should work with the relevant agencies to make sure the necessary steps are taken. The statutory guidance Working Together to Safeguard Children sets out how all practitioners working with children and families need to understand their role in this regard.

[Baroness Keeley (Lab)]

I just want to reflect that the noble Lord, Lord Young, said in his speech that young carers services almost never receive any referrals from adult mental health services, despite the provision that already exists and has done for a number of years in codes of practice. This is a difficult thing—I tried to bring in legislation for that in the other place on a number of occasions. I just thought that was worth pointing out.

[Baroness Merron (Lab)]

I thank my noble friend for pointing that out. On the points raised about protections for young carers, the code highlights that children who are caring for parents with severe mental illness are entitled to request a young carer’s needs assessment under the Children Act. It goes on to cover the information that young carers should be offered to help navigate such a challenging time.

Returning to the guidance about which I was speaking, as has been identified, it already outlines the responsibility of multiagency safeguarding partners. Protecting children at risk of abuse and stopping vulnerable children falling through the cracks is very much at the heart of the Children’s Wellbeing and Schools Bill, which was introduced to Parliament last month.

[Baroness Watkins of Tavistock (CB)]

I thank the Minister. I want to raise the issue that so many children and adolescents are placed for care out of their area, which makes the subsequent treatment plan hard to manage. Can the Minister at least look at whether the code of conduct needs strengthening on that issue? For example, it could include a recommendation that a local team visits the person in the hospital before they are discharged. Of course, I would like to see more beds closer to home, but we have to face the reality.

[Baroness Merron (Lab)]

I appreciate that point, and I certainly would be happy to have a look at that.

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[Lord Kamall (Con)]

My Lords, during the debates on this Bill—and throughout my time in this place—I have learned that there are specific topics about which other noble Lords are passionate. For example, the noble Baroness, Lady Hollins, who is not in her place for sad reasons, is passionate about many issues; but, in the context of this Bill, she has long championed issues around the detention of those with autism and learning disabilities, as has my noble friend Lady Browning. My noble friend Lady Berridge is very passionate about children and young people and about tackling racial discrimination, and the noble Lord, Lord Davies, is very passionate about the link between finance and mental health. Many noble Lords are passionate about specific issues. For me, Amendment 138, in my name and that of my noble friend Lord Howe, goes to the heart of an issue in which I very strongly believe, based on my own experiences of racism while growing up in Britain.

Before I go into that, I will touch on the amendments from by the noble Baroness, Lady Whitaker. In one of my first work experiences—in Chase Farm Hospital many years ago—I got to know and speak to a young patient from the Traveller community. He told me about the problems that the Traveller community had in getting access to medical care, and how members of the community were always treated with suspicion and not in the same way. So I am very sympathetic to those amendments.

To get back to my own experience, the Britain of recent years, which my children grew up in, is much less racist than the Britain that I grew up in the 1970s and 1980s, when it was common to be called offensive names or to be chased by skinheads, sometimes actually with weapons and knives. But my experience was a lot better than the racism that my father faced when he came here in the 1950s. There are horrendous stories that he told my siblings and me when I was younger. I believe that we can be proud of that progress, as a country and a society.

When I was a Member of the European Parliament, I used to chat to the taxi drivers in Belgium and France. I would tell them that I was from London, and not all of them but many of them would say how lucky I was, since they had a friend or relative in London and they thought that London was incredibly diverse and tolerant compared with where they lived. That was very touching to hear—but I have to admit that that is my experience, and some will have had different experiences. Even my experience does not mean that the battle against racism and racial disparities is over. As many noble Lords, including the noble Lord, Lord Davies, the right reverend Prelate and my noble friend Lady Berridge, have rightly said, we have to be vigilant on this.

As the noble Baroness, Lady Tyler, said, one reason for the review and this Bill is because my noble friend Lady May commissioned the Wessely review due to the disproportionate number of black people being issued with community treatment orders or being detained; noble Lords have referred to this. We have known about that issue for a long time. Although politicians in the other place and many noble Lords here have raised the issue many times over many years, we do not really seem to have grasped the issue or to be on top of it. When I ask colleagues and medical experts about the disparity, I get a variety of answers. In the absence of any widely distributed and comprehensive study, the vacuum is filled by anecdotes or assumptions, sometimes racial stereotypes. One of the most common responses I have heard is that it is complex or multifaceted.

I remember when I did not initially get into the local grammar school, despite having the best grades in the class—better than some of the white pupils who got into the school; it also happened the previous year, in the year above me, when one of my friends who was black, an Afro-Caribbean, topped his class and did not get into the local grammar school—and my mother challenged the decision and asked for the reason, she was told “It’s complicated”. Fortunately, she persisted, and I got my place thanks to the help of my local Member of Parliament, who later became the late Lord Graham of Edmonton, may he rest in peace.

So when I hear the response, “It’s complicated”, I hope noble Lords will understand that I am simply not satisfied with that answer. It is just not good enough any more. The purpose of my amendment is to probe the Government to understand what they know and what research they are aware of, so we can understand the reasons for these racial disparities and put in place measures to tackle them. If it is complicated, can the Government or NHS list the various reasons and say what they are going to do about it? As noble Lord after noble Lord has said, we need the data.

The noble Baroness, Lady Barker, who is not in her place, reminded noble Lords that many of the answers from the Minister sound similar to the responses from 20 years ago. That is not a political point. I suspect that the answers given by the Minister, who is well liked and respected, would not be very different from the answers prepared by officials for any Health Minister of any party. Some of the answers are probably very similar to answers that I gave when I was a Minister. That is not to disrespect the diligent civil servants in the department, who work really hard, but we need answers to the following questions.

What studies are the Government, DHSC and NHS aware of? What do we understand from the various studies? What secondary data do we have, and what are the known unknowns? What do we know that we need to know more about? Has there been any attempt from that secondary data to generate the questions for the primary research so that, once and for all, we can understand why a disproportionate number of black people are subject to community treatment orders and to being detained? Do the Government, DHSC or the NHS, if they have the data, know how to use it to reduce those disparities? If so, when will they begin to reduce these disparities?

I was very pleased to hear a reference to some of the pilot schemes. Perhaps the Minister can refer to some of those schemes, and maybe that would be helpful. But I have to say that if the answers that we receive to these questions, either tonight or when the Minster writes to noble Lords between now and Report, are not adequate, I suspect that noble Lords will have to send the Minister back to the department to kick the tyres and get a better answer. It is as simple as that; otherwise, I am afraid that we will return to this issue on Report. If it comes to that, I hope that we will not see a Government urging noble Lords from the governing party to vote against an amendment that would seek to tackle these huge racial disparities in a methodical way and with an evidence-led approach. I look forward to the Minister’s response.

[Baroness Merron (Lab)]

I thank noble Lords for the points they have made. I shall start with those from my noble friend Lady Whitaker regarding Amendments 63, 101, 107, 113, 116 and 124 and immediately address the point about the limited available data on Roma communities.

I absolutely acknowledge that the data on Gypsy, Roma and Traveller communities is indeed very limited. I emphasise that I say this not as an excuse; it is just what I have discovered. This is largely due to lower numbers, but we are working with NHSE to improve ethnicity reporting for all patients. More broadly, the Office for National Statistics is working with a range of government departments to undertake research into the barriers and enablers for this community in accessing a range of public services, including mental health services. Findings are expected later this year. I know my noble friend has been very active in pursuing this point and I am grateful to her for doing that. I hope that will be a generally helpful response.

I add to all noble Lords that I absolutely agree that information, communication and support should be provided in a culturally appropriate manner. However, we do not believe that the amendments would achieve that aim, nor are they necessary. The duty to take cultural differences into account in how services are delivered is already enshrined in the Equality Act 2010. These existing duties are the legal basis for ensuring that services are culturally appropriate. That said, we absolutely acknowledge that, in practice, many services still fall short, but that is the position that we find ourselves having to tackle. This is where we need to strengthen guidance. The patient and carer race equality framework is already in place to strengthen the application of these principles, and we will strengthen guidance in the code to ensure that duties under the Equality Act are embedded in practice. We therefore believe that these amendments would not have any additional benefit above what is already in place and what is planned.

On Amendment 65, tabled by the noble Baroness, Lady Tyler, we recognise that there are very significant disparities in the use of community treatment orders between different groups. This data is published as part of the annual Mental Health Act statistics. As the noble Baroness said, in 2023-24 it certainly was the case that patients from black and black British ethnic groups were around seven times more likely to be placed under a CTO than those from white groups. I add that patients from all minority ethnic groups are more likely to be subject to the use of a community treatment order than patients who are white. These disparities are explored in the impact assessment.

The noble Lord, Lord Kamall, drew on his personal experience, for which I thank him. I am sorry that he has to bring that personal experience here, but of course it is the case that the battle against racism and racial disparities is far from over—I completely agree. I am sure he will have noted the commitments made by this Government to tackle racism and racial inequalities, particularly in the NHS and social care.

The reality is—many noble Lords have spoken about this—that we are in a position where we have less data on outcomes and patient experience of being subject to community treatment orders. Officials are now working with NHS England and system partners to understand what additional data it would be wise and helpful to collect. We will cover CTOs in the planned independent evaluation of the reforms but, as ever, I have to share, in honesty, that it will take time to gather new data. A review after 12 months would be premature, not least because it would mean it was based on data from before any reforms commenced. I do not feel that that would be helpful. I assure noble Lords that, rather than committing in legislation to a review at a fixed date, we are committed to keeping existing and additional future data under review.

[Lord Scriven (LD)]

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

[Baroness Merron (Lab)]

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

We agree there is a need to improve organisational leadership—

[Baroness Berridge (Con)]

Just before the Minister talks about that point, I understand her concern about the 12-month time limit, because it would be before the reforms are introduced. However, is she satisfied that there will be a robust baseline before the reforms are introduced so that we know what we are measuring against? Otherwise, in a few years’ time, we could be asking whether the reforms have worked, but we would not know because we did not have the baseline data. That is the starting point.

[Baroness Merron (Lab)]

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

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

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

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

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

[Lord Scriven (LD)]

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

[Lord Kamall (Con)]

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

[Baroness Merron (Lab)]

I was about to say that I do understand the need for pace, but I know that noble Lords understand the need to get this right and I know they are not suggesting that we should get it wrong. I will certainly be glad to look at the points that have been raised. I assure noble Lords that I do not want this to be warm words and I understand what noble Lords are seeking. I want to ensure that it is right and that the pace is right. I will look at the points raised because—although I do not think anyone is accusing me of this—it is the exact opposite of avoiding accountability and transparency; it is just about dealing about what is in the amendments.

The noble Lord, Lord Kamall, asked me a number of very pertinent questions and to do justice to them I will write to him. In conclusion, I hope that noble Lords—

[The Lord Bishop of Manchester]

Before the noble Baroness sits down, could I tease out from her a few words about the religious literacy point that myself and the noble Baroness, Lady Berridge, raised earlier? While we have rightly focused much on race and ethnicity this evening, which is important, I find that sometimes people take a pride in being religiously illiterate and in not paying attention to somebody’s faith in a way that they would probably not take a pride, as a professional, in not attending to somebody’s ethnic background. Does the Minister have a little word to say about that?

[Baroness Merron (Lab)]

I suspect that the right reverend Prelate knows where I would be coming from on this. He and the noble Baroness, Lady Berridge, are quite right that consideration of one’s religion and religious practices and not making assumptions about them are absolutely crucial.

[Baroness Whitaker (Lab)]

I thank my noble friend for her understanding of the crucial meaning of the data shortage and for her very helpful account of further work. The problem with relying on Gypsy, Roma and Traveller being covered by equality legislation guidance is that, unless they are specifically named as what they are, lots of people have no idea that they are there, that they are subject to an appalling level of discrimination and that they need a targeted response, directed—as it would be with a faith community or other community—at the reason they are so discriminated against.

But, on the whole, I am glad that the Minister has got the point about so many things and I sense that she has sensed the depth of feeling raised in this very short debate. I will thank very briefly everyone who joined in. The noble Baroness, Lady Bennett of Manor Castle, quite rightly pointed to the range of cultures that are potentially alienated by not being understood at all, as well as the need for data. I was very grateful for the support of the right reverend Prelate the Bishop of Manchester, because what he says is based on his real experience. I am very glad that my noble friend Lord Davies went on about the centrality of this issue; it is not a marginal add-on, it is part of our society. Of course, the plea of the noble Lord, Lord Kamall, for more research and proper data is really essential. I enjoyed his note of hope and I hope very much that we will be able to continue it and increase the progress. I had better withdraw my amendment for the time being, but we may need to return to this.