Mental Health Act 1983

Julian Lewis Excerpts

Thursday 25th July 2019 Westminster Hall

[Dr Julian Lewis (New Forest East) (Con)]

Thank you, Ms Buck, for calling me so early in this debate. I am sure that I speak for everybody who listened to the remarkable speech of the hon. Member for Bermondsey and Old Southwark (Neil Coyle) when I say that it was a privilege to do so. We should all be immensely grateful to him for illustrating the important policy points that he had to make by means of his agonising experiences in his immediate family in his very early years. We all thank him for it.

Given how many hon. Members wish to contribute, I will speak very briefly. I note that the hon. Gentleman’s speech was briefly interrupted by some shouting outside the Chamber to do with Brexit; it seems to be a common theme that mental health debates tend to happen at times when they are overshadowed by other issues. For example, when I became a Member of this House in 1997, I came second in the private Member’s Bill ballot. I chose to introduce the Mental Health (Amendment) Bill, which was designed to achieve improvements for people who suffered catastrophic breakdowns such that they needed to be admitted to acute mental health units.

At that time, the person who came first in the ballot chose to address a subject of massive national importance, namely the banning of hunting with hounds, and I could not help but notice the contrast between the packed main Chamber on the Friday that was considering the welfare of foxes and the rather more thinly occupied main Chamber a week later, as was customary, when we were trying to consider the welfare of human beings. It was ever thus.

The points at issue then are, to some extent, still points at issue now. They have already been touched upon, at least in part, in the excellent opening speech that we have all heard. My particular concern was the need for there to be separate therapeutic environments for people who had to be admitted to acute units who suffered from very different types of mental illness. In other words, the idea that somebody suffering from acute depression should be cheek-by-jowl with somebody suffering regular psychotic outbursts was obviously a recipe to make a very serious situation even worse.

While I was doing the research for that debate, it was drawn to my attention by staff at acute units that their particular nightmare was the thought of what would happen if there was inadequate staffing coupled with mixed-sex wards. I was really rather shocked and shaken today to hear the statistics cited by the hon. Member for Bermondsey and Old Southwark about the level of danger of sexual assault among in-patients, because for quite a number of years I and various other colleagues waged a campaign to abolish mixed-sex wards in mental health in-patient facilities. At first there was talk of separate bays, if I recall correctly, which by no means would have answered the necessities of the problem. And successive Governments kept saying that they would do it, and even that they had done it, so it is particularly disturbing to hear about the level of concern that still exists about this issue.

The question of inadequate numbers of beds has already been touched upon by the hon. Gentleman. It has to be said that, for once, this is not the responsibility or fault of Government, because after the closure of so many of the large asylums, the pendulum—in my opinion, and I am not an expert; I have to say that I am not a medical doctor—swung too far the opposite way.

I remember, in the New Forest area, having to fight a bitter campaign—which ultimately failed—to prevent a 35% reduction in in-patient beds in acute units. If I remember correctly, two of five units were closed. We were prepared to compromise and say, “Close one of the two units. Close 16 of the beds, rather than 32, and see how you get on,” but the authorities would not listen and they forced the closures through. It was the Southern Health NHS Foundation Trust, which later became notorious in the mental health sphere for other reasons, that forced through the closure of all these beds, and the system has been rammed and overflowing, and under excessive pressure, ever since.

There was another knock-on effect of the swinging of the pendulum too far back from the correct policy of closing the larger asylums, and that was that, by having fewer permanent facilities, we lost the ability to have what was technically—or maybe not very technically—known as the “revolving door”. This was the idea that, yes, if we could get more people back in society, so that they could make their own way and live their lives freely and without having to be in-patients, the very existence of a network of permanent establishments—albeit for other purposes—meant that there were always plenty of opportunities, so that if somebody felt that a trough was coming they could seek help easily for, as it were, almost a top-up of treatment, just for a few days. That would then set them back on track and it meant that they would not suffer—

[Neil Coyle]

indicated assent.

[Dr Lewis]

I am delighted to see the hon. Member for Bermondsey and Old Southwark indicating his agreement. It meant that they would not then suffer a much worse breakdown, which would have meant that they would have to be incarcerated, for want of a better word, for a much longer period.

[Debbie Abrahams]

To prevent people, including people living with dementia, from having to be admitted to hospital, there needs to be community support and after-care support once people are discharged, to ensure that they can be kept as healthy and independent as possible in the community for as long as possible.

[Dr Lewis]

The hon. Lady is absolutely right, as long as we recognise that what is needed is a range of facilities. Even the most ardent advocate of doing away with in-patient beds would, if pressed, admit that there will always be some people who at some point absolutely need to have some in-patient treatment.

If there are some people who need to go in for a considerable period of time, and hopefully there are a lot more people who do not need to be admitted to acute units at all, it follows almost logically that there will be some people who are on the borderline between the two, who can get by in society with a degree of self-awareness—either their own or that of their immediate family—and that when the warning signs appear, provided there is that network of specialist care with beds for very short-term stays, they can receive what I call a “top-up”, or, if we were talking about servicing a vehicle, something that will prevent a much greater collapse from happening later, with all the consequent horrors.

The question of what happens when people are admitted to acute units arose on a second occasion. I mentioned the first occasion, when I tried to introduce my private Member’s Bill in December 1997 and it was overshadowed by foxhunting. On a second occasion—on 9 December 2010, to be precise—I had secured an Adjournment debate on what happens about the information that is given to someone’s nearest and dearest when an adult is sectioned and goes into an acute unit. That occasion was on the day of the key debate about the trebling of student tuition fees, so once again we found mental health being somewhat upstaged by other matters that were of national importance. However, that is no reason not to persist or not to continue to try and emphasise to Ministers how these issues will never go away until they are finally tackled.

On that occasion in December 2010, I raised the case of the daughter of my constituents, Mr and Mrs Edgell. Sadly, their daughter—who was called Larissa but known as Lara—had taken her own life in 2006. For two years prior to that, the medical authorities had refused to share information about her with her parents; because she was an adult in her thirties, they refused to share vital information about her suicidal thoughts with her parents, on the grounds of patient confidentiality.

It subsequently turned out that there were very good guidelines that said that such information should be shared. So, I wrote to the then Minister with responsibility for care services, the hon. Member for Bury South (Mr Lewis), saying that there was clearly a breakdown in the system if adequate rules existed but were not being put into practice locally. The rather unsatisfactory answer that I received at the time was that the responsibility lay with the local medical authorities to ensure that the central guidelines were implemented.

As I say, that was at the end of 2010, so it was a long time ago. I wonder whether the Minister will be able to reassure me that there is now more central direction. In the case of Lara and her parents there was inadequate sharing of vital information, under the mistaken belief that patient confidentiality trumped the fact that an adult patient was incapable of making her own decisions. I would like to know whether that situation has been rectified, or whether we are still dependent on local medical institutions and authorities to apply a central guideline that ought to be better known.

This week, I received a letter from Lara’s mother, who asked me to attend this debate. I can do no better than to read from what she says, not so much about what happened to her daughter but about the continued interest that she has in the workings of the mental health services. She says that she would like to make her own recommendations; given what happened so tragically in her immediate family, we owe it to her to give serious consideration to those recommendations, which are as follows:

“1. The 1983 Act should be revised to prioritise the dignity of individuals who come to be in the Service’s orbit.

2. Such individuals should have their values and world views respected and have a significant say in the manner of their treatment.

3. They should have the option to refuse certain treatments.

4. Mental hospitals must be places where patients feel safe: there have been numerous allegations of staff members being abusive, provocative and/or intimidating.

5. Use of force should be absolutely minimised. This includes physical restraint, seclusion, or forced medication.

6. A reduction in ‘sectioning’.

7. A reduction in stigma”—

and finally:

“8. All aspects of the Mental Health Service should be more open, and subject to independent scrutiny from time to time.”

I will conclude by making one left-field observation relating to the armed forces. The Select Committee on Defence, which I have the honour of chairing, has been recommending for some time that we establish a centre of excellence for the mental injuries suffered by those who put their life on the line to defend this country, preferably alongside the national centre for physical rehabilitation at Stanford Hall. We have now raised this issue twice with the Secretary of State for Health and Social Care, who has given us a reasonably encouraging response. However, once again, we feel that he is coming up against resistance because of the philosophy that people must be treated locally when at all possible, not admitted as in-patients in centralised locations. That is causing a pushback against our idea.

Our idea is based on the fact that those who suffer injury in combat situations have experienced a peculiar and unique form of trauma, different from those that ordinary mental health professionals can be expected to understand. I am sure that my hon. and gallant Friend the Member for Plymouth, Moor View (Johnny Mercer) will want to expand on that topic, if he is lucky enough to catch the Chair’s eye. We believe that there is a case for a national centre of excellence, and that the welfare of members of our armed services who suffer mental injury should be no less important to us than the welfare of those who suffer other, physical forms of injury in the cause of defending our freedom.

--- Later in debate ---

[Jackie Doyle-Price]

I cannot give the hon. Gentleman a straightforward answer to that question but I will write to him with a commitment. It is very boring, but Brexit has diverted officials in the Department. Obviously, no-deal preparations in the health service are a matter of public concern, so we need to make them, but we still need to get on with business as usual. It is an important issue.

The hon. Member for Worsley and Eccles South (Barbara Keeley) mentioned the case of Matthew Leahy. I will go away and reflect on that, but I will give the same message as I gave in response to Seni’s law. Generally, we need to get a proper grip on how we learn from deaths that happen when somebody is in the state’s care, because that is clearly unacceptable. We have coronial reports of all those occasions. People should not be waiting the length of time that they are waiting for inquests. When inquests happen, again, there is usually representation from the various institutions involved and the family can be left feeling very under-represented against a mass of organisations trying to avoid liability. We need to tackle that properly.

We have had those discussions at the ministerial board. My ministerial colleagues in other Departments and I want to get a grip on how we properly hoist in the learnings from coronial reports. I look forward to engaging with hon. Members on that, but I will write to the hon. Lady specifically on the issue of Matthew Leahy. It is worth noting that we are looking at the principles of sexual safety in wards, which is not just about getting rid of mixed-sex wards. People are very vulnerable in those situations and it is all about the care regime.

[Dr Lewis]

Can the Minister tell us in simple terms what the situation is regarding the continuation or discontinuation of mixed-sex wards in mental health acute units?

[Jackie Doyle-Price]

On mixed-sex wards specifically, I cannot tell my right hon. Friend what the proportion is, but we are ensuring that the guidance on sexual safety on mental health wards is being rolled out. I will write to him specifically on that, if he will indulge me.

--- Later in debate ---

[Jackie Doyle-Price]

As far as legislation is concerned, ultimately people with autism who are suffering from mental ill health will be detained under the Mental Health Act. Perhaps we ought to pick up how that interacts with other legislation as we develop the White Paper. The overlap is a clear problem.

I have paid tribute to Sir Simon Wessely. We are all about making sure that our reforms deliver genuinely person-centred care. We should be removing coercion and control as far as we can.

My hon. Friend the Member for Plymouth, Moor View (Johnny Mercer) talked about Georgi Lopez, who addressed the all-party group and whom I had the pleasure of meeting. She tells a compelling story about her contrasting experiences. She readily concedes that on one occasion being detained under the Act was the best thing that could have happened to her, but on another occasion it did her genuine harm. In fact, Members who read Frank Bruno’s book will find exactly the same story. It is almost as if once someone is on that pathway and under detention, they will always be seen through that prism. We need to tackle the underlying prejudice. People who are suffering from mental ill health are vulnerable; they are not an inconvenience. Any services provided by the state need to be working with them to support them, not to do them harm.

Our overall objective when we asked Sir Simon to look at the Act was to reduce the rising number of people detained under it. I hope that underlines the spirit with which we are approaching the inquiry. We also asked him specifically to address the disparities in how the Act is used, highlighting in particular the impact on black and ethnic minority groups, but also on women. It is of great credit to him that he went much further than that and led a full review of the entire Act. Again, that raises the expectations on me to deliver fundamental reform—but that is fine; it is what I am here to do. He did so with such speed, and having taken so many with him, that he has provided exactly the right conditions to approach reform.

Sir Simon built relationships with service users and carers, and I am riding on the back of them. I meet those people regularly to hear directly from them about their responses to his recommendations. We will continue with that. I have been struck by some of the experiences shared with me by service users and family members, which bring home how disempowering it can be. I often talk about the arrogance of medical professionals who, when someone turns up and says, “Fix me,” send them along. That dismissiveness can be more so in mental health than anywhere else. We need to ensure that we put in a regime that treats people with dignity and respect.

At the heart of this issue, the current Act has much too big a disempowering effect, which does too much to remove people’s autonomy and not enough to support their decision making and influence over their own care. It is dehumanising. We should look at detention as the last resort, because it does genuinely do harm. That is not to be critical: staff will act with the best of intentions, but a lot of it depends on culture. When Georgi Lopez shared her experiences, she talked about the two very different cultures of the organisations in which she was detained. When the CQC visits such places and assesses whether they are well led, it must assess the culture and whether patients are genuinely empowered.

I do not think we should duck the fact that sometimes we will have to detain people for their safety and that of others, but we need to ensure that we have the right guarantees in place. I am struck by something that Sir Simon always says: from the moment of detention, release planning should start there and then. A credible care plan is all about getting people back out and re-empowered. It should be based on consent and empowering the patient.

As has been mentioned, Sir Simon’s report contains 154 recommendations. I will work with the Ministry of Justice on a joint White Paper from both Departments, which will come forward by the end of the year. We have already started to implement the recommendations that we can, and I hope that Members are reassured by how, last week, the previous Prime Minister re-emphasised her commitment to making sure that we tackle the issues regarding black and ethnic minority detainees. I know she will continue to have a full interest in these issues from the Back Benches. I reassure the hon. Member for Worsley and Eccles South that if she sees no sign of a White Paper, she has a good ally on the Government Benches to hold the Government’s feet to the fire. I look forward to engaging with all hon. Members on those recommendations when we come forward with our White Paper, for which we should also consider the issues that have been highlighted during the debate.

As I have said, we want to modernise and ensure that people who are detained under the Act receive better care by improving patient choice and autonomy in their treatment. We will introduce statutory advanced choice documents to enable people to express, in advance of detention, their view on the care and treatment that works best for them.

It is important to talk about the role of family, because we have agreed that patients should be able to identify a nominated person who will have the power to look after their interests under the Act. At the moment, the next of kin is the default. I have heard compelling evidence from patients who have said that that is not always appropriate. Family members can often be a source of abuse or additional pressure and harm, so patients want to be able to nominate someone, which seems extremely sensible. I recognise that that will cause some controversy.

[Dr Lewis]

The Minister says that that seems extremely sensible but if, for example, somebody is seriously mentally ill and imagines that their parents mean them harm when they are actually doing everything they can in support, should the parents be locked out from knowing what is happening to their child?

[Jackie Doyle-Price]

We will have to have that debate. My right hon. Friend articulates the opposing position to what I have heard. I regularly hear his example when I chair the national suicide prevention panel. We have had dialogue with NHS organisations and there is a consensus statement setting out the framework by which reports can be given to family members. Equally, patients who are detained under the Act should be able to say which family members should not be consulted about their treatment. For example, we see women who are victims of domestic violence and abuse by their partner and find themselves detained under the Act; their partner would normally be their next of kin, but it would not do those women any good for that person to be contacted.

[Dr Lewis]

I quite agree, but my debate was nearly nine years ago. Is it not a bit late in the day for the Government to say, “Well, we are having a conversation about this?” At the time, there seemed to be some quite sensible rules, but the main problem was that the local mental health authorities were not applying them. If anything, it seems that we are further away from our objectives than we were nine years ago.

[Jackie Doyle-Price]

I think my right hon. Friend misunderstands me. We have a consensus statement that governs how NHS organisations and practitioners should deal with people at risk of suicidality, although there is concern among bereaved families that it is not always followed. Equally, in delivering a service that empowers patients, those patients should be able to identify their nominated person. Those discussions take place much more frequently when people set up new relationships with NHS practitioners. When they change GP, for example, they are invited to nominate a person, in case there are any safeguarding issues.

--- Later in debate ---

[Dr Lewis]

I hesitate to intervene one last time. I fully accept the Minister’s point about abusive partners, but what if the person is desperately, seriously ill and delusional, and the mother is not allowed to be told information about their offspring, because they are technically an adult? At what point do you decide that the person has lost capacity to identify correctly with whom information should or should not be shared?

[Jackie Doyle-Price]

That highlights the importance of having a nominated person earlier in the journey. I do not disagree with my right hon. Friend, but he highlights the difficulty of our work to get the balance right between keeping someone safe and respecting their wishes. I fully anticipate that when we produce the White Paper on this issue, he and I will probably have another debate about it. It is important that we get it right, with the safety of the patient in mind while empowering them to make their own decisions.

I have already mentioned that we will end police stations being places of safety under the Act, and that will be included in any legislation. On equalities, we are working with the NHS to introduce the first ever race equality framework to ensure that mental health care providers work with local communities to improve the ways that patients access and experience treatment. An important point is that although we are concerned that under the Act there are far too many detentions of people from black and minority ethnic communities, it is possible that is partly because they find it difficult to access services. We need to address that properly.

To help to address that, we are also launching a pilot programme of culturally appropriate advocacy. Clearly, we will need to make that resource available to ensure that people have access to it. The review said that we need to learn a lot more about that whole issue, so we will work with the National Institute for Health Research, which will launch a call for research later in the year to give us more answers. Jacqui Dyer MBE is our Mental Health Equalities Champion, and she will play a leading role in taking forward the review’s recommendations on tackling the injustices faced by black and minority ethnic services users.

I have spoken for quite some time; I hope I have covered most of the aspects mentioned. On the issue of funding, I have probably bored everyone senseless by saying that we are determined to deliver a much-expanded service, and our focus must be on developing those community services. We have made resources available to do exactly that through the long-term plan, but that is not to say that the issue is not still challenging. However, I hope we will be able to do much more in the community for people with severe mental illness, so that we can treat them in the community rather than have them go into crisis care.

To illustrate that with an example, if we can get people out of beds and into the community, the ability to look after more patients is really stark, so it starts to pay for itself. I discussed that with a clinical director from the NHS, who said that if they remove three people from in-patient beds and have them in the community, the productivity is so much greater straightaway. We rely on good local leadership to crack that and make it happen.

I have covered most of the things I wanted to. I will just reiterate my thanks to all Members who have participated in a very good debate, and I look forward to having discussions on the White Paper as it develops.