Mental Health Act Reform

Baroness Tyler of Enfield Excerpts

Monday 18th January 2021 Lords Chamber

[Baroness Thornton (Lab) [V]]

My Lords, the whole House will welcome this White Paper. The overhaul of the Mental Health Act has been long awaited. It is also to be welcomed that the Government have accepted the majority of the recommendations from Sir Simon Wessely’s independent review of the Mental Health Act. As Sir Simon Wessely’s report highlighted, there is a great need for patients to be heard, for their choices to be respected and for them to be supported to get better in the least restrictive way.

Although legislative changes are important, the best way to prevent people being detained under the Mental Health Act is to prevent them reaching a crisis point in the first place. This means bringing reality to equality for mental health, bringing in investment and training, and introducing a culture change in the NHS.

My first question is whether the investment detailed in the long-term plan will be sufficient to achieve that. Many of the organisations which have championed mental health doubt that it will. Surely we will require greater investment to implement the proposals of the White Paper.

The Government accept almost all the review’s recommendations on advocacy and tribunals, including the funding that will be required to implement them. These are key reforms affecting people’s liberty and will play an important part in making other improvements to people’s rights effective. Can the Minister assure us that planned reforms will be fully funded?

The independent review was published over two years ago. Since then, the murder of George Floyd and the growth of the Black Lives Matter movement have brought the impact of structural racism into greater focus. Among the five broad ethnic groups, the known rate of detention for the black or black British group—321.7 detentions per 100,000 of the population—was over four times that of the white group, which was 73.4 per 100,000. Men and women from African-Caribbean communities in the UK have higher rates of post-traumatic stress disorder and suicide risk and are more likely to be diagnosed as schizophrenic. Does the White Paper go far enough in tackling the racial disparities within our use of the Mental Health Act? It is very much to be welcomed that the Secretary of State has announced the new patient and carer race equality framework, which was recommended by Sir Simon Wessely. Can the Minister tell us the timetable?

On health inequalities in general, children from the poorest 20% of households are four times as likely to have serious mental health difficulties by the age of 11 as those from the wealthiest 20%. Half of LGBT people—52%—have experienced depression in the last year. One in eight LGBT people aged between 18 and 24 say that they have attempted to take their own life in the last year. Almost half of trans people have thought of taking their own life in the last year, and 31% per cent of LGB people who are not trans say the same. People living in the most deprived areas are more likely to be referred to an IAPT service by their GP but are substantially less likely to receive a complete course of treatment or make a successful recovery. Long-term funding decisions will be needed in the next spending review. What will they look like? Will the Government make a long-term commitment to invest when this is required?

I am sure we all welcome the aim to improve how people with learning difficulties and autism are treated under the Act. Will there be limitations to the scope for detention where their needs are due to learning disabilities or autism alone? Do the Government accept all the review’s recommendations on advocacy and tribunals, including the funding that will be required to implement them? These are key reforms affecting people’s liberty and will play an important part in making other improvements come about.

The emergency legislation of the Coronavirus Act 2020 represented a concerning reduction in patient rights and safeguards. While we understood the reasons for their initial introduction, I am sure that everyone is glad that they were never enacted and pleased that they have now been dropped. However, Covid-19 will prove a defining moment for the way in which we discuss and protect our mental health. A rising tide of people who have not previously experienced mental health problems now find themselves in that position. For a lot of people, the pandemic has seen a shift from merely “struggling” to becoming clinically unwell. Funding and reform will be needed more than ever.

Finally, can the Minister tell us when the legislative programme will commence? Is there to be a joint pre-legislative scrutiny committee? I believe the Minister’s right honourable friend the Secretary of State suggested that that might be the case. That would be very welcome and I hope that it will start very soon indeed. When, finally, will we see the draft Bill?

[Baroness Tyler of Enfield (LD) [V]]

My Lords, there is much to be welcomed in this White Paper, for which we have waited so long. I am pleased to see patient voices being put front and centre of plans and proposals to address the current shocking disparities in the rates of detention of people from black and minority-ethnic backgrounds. However, the issues that were highlighted in the Wessely review two years ago have continued to scar the lives of too many people during the extremely long gestation period of this White Paper.

The original legislation is 40 years old now and out of date. It is shocking, frankly, that it has taken us so long to amend archaic processes, such as an individual’s father automatically being their advocate in a mental health crisis, whatever the nature of the relationship or preference of the individual patient.

I understand the importance of getting the details right. However, I was concerned by the lack of urgency shown by the Secretary of State when responding to questions from MPs on the Statement last week. Why do we have to wait another year before the legislation can even begin? Can the Minister give us a concrete timeframe for the further consultation? What is the timetable for taking forward the non-legislative reforms in the Wessely review, not least to achieve wholesale cultural change in mental health services?

I am similarly very concerned about workforce issues facing this sector. Many of the workforce aims laid out in the NHS Long Term Plan are not on track to be met, with 12% vacancy levels in many mental health services. Between 2016 and 2019, demand for services increased by over 20%—and that takes no account of the exponential growth in mental health problems during the pandemic. Recent forecasts suggest, for example, that only 71 additional consultant psychiatrists will be added to the NHS workforce by 2023-24, against a requirement of more than 1,000 to deliver the long-term plan. What measures are the Government taking to address the additional workforce requirements of reforming the Mental Health Act?

We then come to the issue of funding. The short-term injection of £500 million is, of course, welcome, but it is sustainable and long-term investment in services—covering the full spectrum from preventive to crisis care—that we so badly need. We need a comprehensive plan for funding all existing and new mental health services, rather than one-off injections of short-term funding. Above all, this means investment in community services. In a survey of Royal College of Psychiatrists members, insufficient access to community health services was cited as the greatest cause of increases in formal admissions. The best way to prevent people being detained under the Mental Health Act is to prevent them reaching crisis point in the first place.

Like the noble Baroness, Lady Thornton, I am deeply worried about the impact of the pandemic on the nation’s mental health. In October last year, the Centre for Mental Health estimated approximately 10 million extra people with mental health needs due to the pandemic—a staggering figure. While it is understandable that we have been focusing on the physical threat of the pandemic and protecting our acute services, when will the Government come forward with proposals to address what some are now calling a mental health emergency?

It is an unpalatable fact that black people are currently 10 times more likely to be placed on a community treatment order. In these situations, patient voices become even more important, ensuring that culturally appropriate services can be provided. The patient and carer race equality framework is a good start; I look forward to hearing more on this issue. I note that cultural advocates are currently being recruited, but can the Minister confirm how many patient and carer advocates will be involved in both the advancing mental health equalities task force and the patient and carer race equality framework steering group? Also, why are the Government not proposing to legislate for a CTO to have a maximum duration of two years or to allow tribunals to change the conditions imposed on an individual by the order, as recommended by the Wessely review?

I end by returning to the issue of prevention. The courses of action covered by this legislation represent the worst-case scenarios for individuals experiencing severe mental health problems. We have so much evidence telling us that investments in preventive measures are highly cost-effective interventions and avoid the trauma of crisis scenarios for patients. While we debate this White Paper, it is vital that we do not lose sight of the bigger picture.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Bethell) (Con)]

My Lords, I thank both noble Baronesses for their incredibly perceptive, thoughtful and detailed questions, some of which I am afraid are beyond the brief in front of me. I reassure them, particularly the noble Baroness, Lady Tyler, that I will write with detailed answers to some of their more perceptive and searching questions.

We are all enormously grateful to Sir Simon Wessely for his thoughtful, persuasive and thorough report. It has taken some time to work on it, but now that it has arrived we will act on it. I reassure the House that it is an enormous priority.

I reassure both noble Baronesses that funding is absolutely in place for mental health. If I may briefly run through that, an extra £2.3 billion a year for mental health services is committed by 2023-24. Some £500 million in mental health investment in the NHS workforce was announced in the spending review, and it will go towards addressing waiting times for mental health services.

The noble Baroness, Lady Tyler, referred to the challenge of recruiting psychiatrists. As she knows, that area is extremely challenging. The employment brand of mental health services is not as strong as it is for, say, surgeons, but we have done an enormous amount through HR and the people plan to find new ways of attracting people to rewarding and challenging roles in psychiatry, and those investments are beginning to pay off.

We have invested more than £10 million this year in supporting national and local mental health charities to continue their vital work in supporting people across the country. I will move on to the mental health effects of the pandemic in a second. We have invested £8 million in the Wellbeing for Education Return programme, which will provide schools and colleges all over England with the knowledge and resources to support children and young people, teachers and parents. We have announced more than £400 million over the next four years to refurbish mental health facilities to get rid of dormitories in such facilities across 40 trusts.

The noble Baroness, Lady Tyler, asked me about urgency and whether the Government were truly committed to moving quickly. I reassure her that money has already been announced and plans are in place to address some of Sir Simon’s most urgent recommendations.

Both noble Baronesses asked about the timetable for legislation. I reassure them that the consultation began last Wednesday; it is a 14-week consultation and we have committed to responding to it this year. If I may advertise to noble Lords, this is a terrific opportunity for all those with views on mental health to contribute to that important engagement. It is our plan to publish the Bill next year on the back of that consultation and for legislative scrutiny to take place next year. The question of whether that will be joint legislative scrutiny is not clear to me right now, but I undertake to both noble Baronesses to inquire and press the case for joint scrutiny when I return to the department. I shall write to both of them accordingly.

The noble Baroness, Lady Thornton, raised the impact of the racial dimension highlighted in the report. The numbers in Sir Simon’s report are incredibly striking and it is crystal clear that this is an issue that we absolutely have to deal with. Will we go far enough? Yes, indeed we will. The framework recommended is extremely powerful and we are already putting it into place. We have learned an enormous amount from the report. The ability for those with mental health issues to nominate their own advocate is an extremely powerful innovation that I think will have a big impact on this issue, but we still have further to go. We are engaged with those who are both representative and expert in this area to ensure that we are challenged to go far enough.

Likewise, on learning difficulties and autism, noble Lords will remember that we have had powerful and moving debates in this Chamber in the last few months on that very issue. I reassure the noble Baroness, Lady Thornton, that we note Sir Simon’s recommendation in his report for a 28-day cap on the detention of those with learning difficulties and autism. It is just not good enough for those with learning difficulties and autism to be detained under a Mental Health Act restraint for an interminable period. That point is thoroughly recognised, and the report’s recommendations are extremely well made.

On the question of the pandemic, the noble Baroness, Lady Thornton, put it extremely well: there has been a shift in many people’s response to the pressures and the isolation of lockdown, from being stressed and anxious to having genuine clinical challenges. The full effects of that have not worked their way through the system so it is difficult to get a nuanced and complete view from the numbers today, but we are very much on the balls of our feet to understand and react to the pressures

If I may draw out one issue, young girls seem to be a demographic who have particularly felt the loneliness, anxiety and uncertainty around the pandemic and lockdown. We are particularly concerned to ensure that support goes to families and individuals who present clinical mental health issues as a result of the pandemic.

On the other, very detailed questions asked by the noble Baroness, Lady Tyler, I undertake to answer them in writing at the earliest possible opportunity.