Mental Health Bill [Lords]

Debate between Ben Spencer and Jen Craft

2nd reading
Monday 19th May 2025 Commons Chamber

[Dr Spencer]

The hon. Member is of course very knowledgeable given his background as a mental health nurse. I would like to see in the Bill a provision setting out that, in order to detain someone for the purposes of health or safety, they must lack decision-making capacity for the detention to be authorised. For the prevention of harm to others, there are reasons to overcome autonomy in decision-making capacity, but I would like to see an additional component specifying that if the detention for assessment and treatment in hospital is purely based on health and safety and not on risk of harm to others, the patient must also lack capacity. Otherwise, people who have full and intact decision-making capacity can nevertheless come into the scope of the powers.

The liberty protection safeguards are a bit of a mess, quite frankly, and the DoLS were clearly a substantial mess. It is interesting that the legislative scrutiny of the Bill points out that it is a missed opportunity not to tidy up some of the interface between the Mental Health Act and the Mental Capacity Act—a point that I will come to a little later in my speech. In terms of parity of esteem, bringing forward fusion law and gelling the Acts closer together needs to be the direction of travel. I hope that we do not have to waste another 20 years until we get the opportunity something like that.

There is something else that we need to reflect on. It comes to my other points about the focus in the Bill, but I will reiterate it. The core focus of the Bill is on reducing detentions of people from black and minority ethnic groups, who are over-represented in detention. One of the key focuses in fixing that must be on socioeconomic deprivation—where we see socioeconomic deprivation, we see severe mental disorder following—but I worry that the Bill is a missed opportunity and will not do what is required to deal with those disparities.

There are three problems with the Bill, and two things that I wish to flag. I am sensitive to the concerns that have been raised about people with autistic spectrum disorders and learning disabilities, and the advocacy regarding such people being in hospital. Being in a general adult ward is a challenging environment as it is, and it is particularly challenging for someone with an ASD or a learning disability. People can get stuck in hospital not really going anywhere. That concern applies to most disorders—I do not think it is unique, given the lack of community support services. I disagree, however, with the focus on ASD and LD above all other conditions. If we want to talk about non-progressive conditions, I do not understand why a brain injury, or Korsakoff’s dementia for example, are not within the scope of this measure. I do not understand why, rather than using the Bill to take people out of section 3 of the Mental Health Act, something like a bolstered treatability test is not used, which is what was in the Act before it was modified in 2007.

[Jen Craft]

I am grateful to the hon. Gentleman, who has brought his wealth of experience to this place. Would he concede that the focus on learning disability and autism is perhaps because those disorders have very specific features? Being in an unfamiliar, over-sensory stimulating or noisy environment, with a break from routine, has an adverse effect on some people precisely because of the nature of their disability, and perhaps more so than for some of the other conditions he has mentioned. Indeed, it seemed something of a weird anomaly that learning disability and autism were classed as mental illness for the sake of the Mental Health Act. I am sure the hon. Gentleman will agree they very much are not.

[Dr Spencer]

I thank the hon. Lady for her intervention. Sensory over-stimulation can be a particular issue for those with autistic spectrum disorders. I have been concerned when I have looked after patients, and I have thought carefully about the challenges, particularly in general adult wards, of catering to the needs of people with autistic spectrum disorders or a learning disability. I would argue that that would apply broadly to anyone in a general adult hospital, irrespective of diagnosis—everyone has particular needs and sensitivities and we need to be mindful of that.

I suspect this is something that the hon. Lady and I will disagree on, but I would consider an autistic spectrum disorder and a learning disability to be a mental disorder. It certainly is under the ICD-10 classification of mental and behavioural disorders. One problem with how this issue is framed in the Bill is, for example, where Rett disorder, which is also a pervasive developmental disorder, would come into it. Does it come under the term “autistic”? Where does a not otherwise specified pervasive developmental disorder come into it? I am not sure whether how the terms in the Bill will operate in real life has been thought through. I do not understand why we are not pushing for such a provision for every disorder and condition that people have when they come into hospital. That is why we are not focused on something like a treatability test, or otherwise.

This has a specific real-life fall-out. If people need to be in hospital after 28 days and there is a deprivation of liberty, that is going to happen. It will not stop happening; with the best will in the world, and even with this Bill, it will keep on happening. People will either be detained under liberty protection safeguards, or they will end up being detained with anxiety related to their ASD or learning disability, which would place them within scope of the Mental Health Act.

A further challenge and disparity in the Bill is that it does not affect forensic provisions. People could be keener to pursue a criminal prosecution of people with ASD or an LD because that would enable a longer stay in detention than 28 days. That is why in the pre-legislative scrutiny we suggested that there should be an option to get a pre-authorisation for detention beyond 28 days by going to a tribunal, which we thought might deal with some of the concerns raised. Personally, I like the idea of pre-authorisation in general beyond 28 days, and it is something that Professor Richardson spoke about in her review back in the late ’90s. The Government recognise that there are challenges with this area, which is why these changes are in the schedules. There is a recognition that, frankly, this is not workable, and we will see as the Bill progresses that there are broader concerns about how it operates.

Another area of concern is nominated persons and parental responsibility. The Bill changes “nearest relative” to a “nominated person”, which means that people can choose who performs that important role under the 1983 Act. The nearest relative or nominated person can discharge someone from the powers of the Act, which would inevitably mean that they would be discharged from hospital—there are powers to bar people, but it is quite a high threshold. This measure is important because it will allow someone under the age of 18 to choose someone who is not their parent to have that important statutory power. We raised this issue in the pre-legislative scrutiny Committee. We could have a situation in which a 16-year-old with competence who is detained under the 1983 Act in hospital chooses their mate, or somebody else—not their parent or someone with parental responsibility—to have the power to discharge them from measures under the Act, which would inevitably mean them leaving hospital. The parent, who in such situations is often responsible in some way for the after care, would lose that power.

I am concerned, as were the Lords, about the impact of that measure on the Children Act 1989. I think there is a serious problem in changing this area of law—we do not have this in physical health—and introducing the ability to give a statutory power to a non-parent. I know the Minister will look into that in the Bill Committee, but I think the Government will have to row back on that. They could easily amend the Bill to say that if someone is under the age of 16, the nominated person must have parental responsibility unless there is a good reason for them not to have it. Sixteen and 17-year-olds are a bit different, especially when people start getting close to 18 and there are other children’s rights, but I cannot see why we should legislate to let someone under 16 choose someone who does not have parental responsibility to have that important power.

The third problem is that the Bill is silent on deprivations of liberty in A&E, which are ongoing. It has been a while since I worked in A&E, but there has always been the challenge of what to do with someone who turns up to A&E if the doctor thinks that they will probably need detaining under the Mental Health Act because they are suicidal or very unwell, and wants to keep them there while the assessment takes place. We can get through it using the Mental Capacity Act 2005, but it is messy. It would be a lot clearer for everybody if we said, for example, that section 5(2) of the 1983 Act, which allows for temporary detention, could apply to an A&E setting. There is a bunch of technical stuff about the interaction between deprivation of liberty and the Mental Capacity Act, but I suspect you will start giving me the evil eye, Madam Deputy Speaker, and telling me to move on if I start—[Interruption.] Madam Deputy Speaker says no, but I suspect that Members across the House might start doing that, so I will move on.

Let me flag two things in the Bill. It allows for a discharge from hospital under supervised conditional discharge to a deprivation of liberty. That is in response to the case of Secretary of State for Justice v. MM, which involves a problem with how the law currently operates. As far as I know, in mental health law we have never had a situation where deprivations of liberty in the community were authorised under the Mental Health Act—someone had to be in a registered hospital. That is a big Rubicon to cross. I see why the Government need to tidy up this area of law, but I am not convinced that we have realised what a big Rubicon this is to cross. The operation of the Mental Health Act has always meant that someone was detained in hospital, but when they are in the community they are in the community. Someone might have certain restrictions placed on them by a community treatment order, or otherwise, but they are not deprived of their liberty in their home or in some other community setting that is not a registered medical hospital. I think that measure needs a bit more reflection.

I believe that the majority of those who will undergo compulsory treatment under detention, certainly for a long period of time, under this legislation will be people with psychosis, such as schizophrenic forms of psychosis, schizophrenia and bipolar affective disorder, but lot of the debate and focus has been on non-psychotic illnesses. That is not to say that those illnesses are less important—they are certainly not less important, especially for those who experience them—but I am concerned that people with schizophrenia always get a raw deal. They are often marginalised by society and in terms of the amount of advocacy they have.

In fact, a lot of the evidence that we reviewed in the pre-legislative scrutiny Committee focused on non-psychotic disorders, perhaps because sadly people often turn their backs on people with psychotic illnesses. Sometimes those people find themselves in a situation where their illness is so debilitating that they cannot advocate for themselves, so there tends to be a bias towards disorders such as dementia, ASD and LD, where there is someone to advocate, such as CAMHS or families who might push a little bit more. I am not saying that any condition is more important—I really want to stress that—but as parliamentarians, we do not necessarily understand that the bulk of the conditions that the Bill focuses on concern psychosis.

Finally, I have spoken a lot about how psychosis can lead to people being detained in hospital and about the impact of that. Psychosis is a pretty terrible disease but it does not need to be: lots of people get better and it is one of the most treatable diseases. The Bill will help people to get better and we cannot lose sight of that.

--- Later in debate ---

[Jen Craft (Thurrock) (Lab)]

The Mental Health Bill is a long overdue update to the Mental Health Act 1983, and I hope it will be the start of a much wider overhaul of a mental health system that is often not fit for purpose and has historically been treated as secondary to the physical health system. It is a system where too often patient voices are ignored, injustices are common and the use of detention is relied upon in the place of person-centred community care. Too frequently, those in acute mental health crisis cannot access the right support. They are refused help in the community, forced to rely on accident and emergency, and detained against their will as their mental health deteriorates. Incidence of detention is three times higher in the most deprived areas. Black British people are detained at 3.5 times the rate of white people, and those with learning disabilities and/or autism are at a unique and increased risk from detention and the impact that it can have on their lives. I will initially focus on that latter group. I declare an interest as the chair of the all-party parliamentary group on learning disability.

Under the 1983 Act, as we have heard, learning disability or autism in themselves can be a reason for detention. The hon. Member for Runnymede and Weybridge (Dr Spencer) said that we will disagree on this, and I am afraid that we will, because I do not think that learning disability or autism are necessarily conditions of the mind. A number of these conditions are genetic and also affect the physical health of a person.

[Dr Ben Spencer]

rose—

[Jen Craft]

I am sure the hon. Member will want to come in on this.

[Dr Ben Spencer]

I appreciate the hon. Member giving way. There is a logical inconsistency, which is that people with autism and learning disability are looked after under mental health services for autism and learning disability. If the argument is, “Well, those conditions should not be within the scope of Mental Health Act”, one could make an argument that they should not be within scope of mental health services full stop.

[Jen Craft]

I thank the hon. Member for his intervention. I would welcome the opportunity to discuss this issue in more detail with him, although we will probably continue to disagree. People with learning disabilities and autism can suffer from mental health conditions as much as the rest of the population, but they have a unique set of challenges. I point out as a note to policymakers in general that they should not conflate learning disability and autism as one and the same thing. That is vital.

At the end of January 2025, 2,065 in-patients in locked mental health facilities were autistic or living with a learning disability. As one of my hon. Friends said earlier, the average length of stay for these patients is nearly five years. For those with a learning disability or autism, a locked mental health ward can be a living hell. For someone with sensory issues, a reliance on routine, a need for a specialist diet or equipment or myriad other needs, being in a busy, over-stimulating environment—often with strip lighting and minimal privacy—often means they are set up to fail from the very beginning.