Mental Health Act 1983

Kerry McCarthy Excerpts

Thursday 25th July 2019 Westminster Hall

[Kerry McCarthy (Bristol East) (Lab)]

As always, it is a pleasure to see you in the Chair, Ms Buck. I congratulate my hon. Friend the Member for Bermondsey and Old Southwark (Neil Coyle) on an incredibly powerful speech that was very detailed and knowledgeable about this issue. Obviously, my hon. Friend was speaking from personal experience, which was very brave of him.

It is clear from the findings of the independent review of the Mental Health Act, published last year, that the current legislation needs significant reform. There has been a 47% increase in detentions under the Act over the past decade, while the proportion of people living with a serious mental illness remains relatively unchanged, so clearly there is some imbalance there; it cannot be right that the number of detentions is going up. I echo the points that have been made about the link between this issue and the cuts to, and failings of, other services in the community that might be able to help at an earlier stage. Perhaps that is one reason why people are ending up in the most serious of circumstances; that is, being detained.

Being detained in a secure mental health unit is obviously going to be an intimidating and frightening experience for anyone. However, it is particularly intimidating for people with learning disabilities and autism, especially young people with those conditions, so I will focus on those groups in my speech. I raised this issue at Health questions on Tuesday, and the Minister—not the hon. Member for Thurrock (Jackie Doyle-Price), but another Minister from the Department of Health and Social Care—gave a very thoughtful response.

One of the things that the Minister said was that learning disabilities, autism or other special needs are often not diagnosed until a child is detained in a mental health unit, which again shows the failings. Child and adolescent mental health services are incredibly under-resourced, and schools are really stretched when it comes to education, health and care plans and working with children who show signs of mental health problems. It is so important that we put proper resources in, so that we can give those children the help they need as early as possible. I am sure that the Minister responding to today’s debate, the hon. Member for Thurrock, agrees with that.

Under the Act, people with learning disabilities and autism can be sectioned with no mental health diagnosis if they are displaying challenging behaviour. The independent review found that the Mental Health Act was

“being used inappropriately for people with a learning disability, autism or both, to deal with a crisis that has arisen because of a lack of good community care or placements…It is particularly intimidating for a person with autism, learning disability or both to be removed from a place they are familiar with or from people they know, even if at the time there seemed little alternative…Instead of improving their mental health, the environment (including relationships with staff) has made them worse, not better.”

One of the common characteristics of autism, for example, is being wedded to routine, and being uncomfortable with unfamiliar circumstances and stimuli that those people would perhaps not get in a more protective environment. That can be particularly challenging.

The Equality and Human Rights Commission echoes such concerns, stating:

“The Commission is concerned about the lack of suitable provision for people with learning disabilities and autism, who may be in restrictive institutional settings because there is insufficient community-based support. The Government failed to meet its minimum target to reduce the number of people with learning disabilities and autism detained in inpatient settings, and at the end of March 2019 there were still 2,260 children and adults living in these institutions. On average, they had spent almost 5 and a half years detained away from home. There were more than 2,600 restrictive interventions recorded against inpatients with learning disabilities and autism in a single month, including physical, chemical and mechanical restraint, seclusion and segregation. Of these, 875 interventions were used against children.”

Most of those people should never have had to go into an in-patient unit, let alone be subject to those types of restrictive intervention. They are ending up in such units because of challenging behaviour due to unmet needs in the community. Those needs, as I have said, should be met with vital investment in community mental health services.

From my experience of people who have come to my surgeries, other casework that we have been dealing with and what I have picked up from visiting institutions, it seems that mental health services suit certain people because of the pathways developed in the NHS, but others do not fit into that category. For example, a child with learning disabilities was rejected for anxiety counselling, and they were later diagnosed with autism. To do the standard CAMHS anxiety counselling, someone has to have a certain ability to rationalise their actions and think about how they operate. That cognitive behavioural therapy-type approach was not suitable for that child, but that meant that nothing was available, because that was the pathway for young girls suffering from anxiety.

I had another case where a constituent was told that she was too traumatised by a recent experience to go through the counselling on offer through her GP. She clearly was not in a serious enough condition to be sectioned, however, so it seemed like she was caught between two things. She clearly needed help, but she was deemed to be too serious a case to get the help that was available. We need to look at the people, rather than just trying to fit them into categories and, when they do not fit into categories, rejecting them from the system, almost as though we are saying, “Come back when you are a lot worse, and then perhaps there is something we can do for you.” That has to be the wrong approach.

Going back to children in particular, the UN Committee on the Rights of the Child has expressed specific concerns about the adequacy of therapeutic community-based services for children. Because of that lack of community provision, children are being detained when they should not be. According to NHS Digital, at least 1,777 people aged 17 or under were detained under the Mental Health Act in 2017-18. Of those, more than a thousand were admitted to a non-local bed, in many cases more than 100 miles from home. Some children and young people under care of Bristol, North Somerset and South Gloucestershire CCG had to travel up to 243 miles away from home for mental health care. That cannot be in the child’s best interests and will add to the sense of isolation and anxiety, and it can also prevent their families from being properly involved in their care.

A recent Children Commissioner’s report found that many parents feel they are being shut out of decisions about their children’s care and are not always informed about incidents involving their children. Serious incidents had happened in hospital without families even being told. Some families had even faced gagging orders where they had been prevented from speaking out about their children’s care. The independent review calls for better safeguards to protect children and young people, ensuring that they are treated in hospital only when necessary and that their rights as a child are clearly set out. There is a need to establish clear tests as to whether children and young people are able to consent to hospital admission or treatment and whether they should be involved in decisions made about them. Clear roles need to be established for parents in care planning and treatment.

The review also states that there needs to be more advocacy available for children and young people. That is particularly important where conflicts arise between the clinical team about how to meet the best interests of the young person, including where contact between young people and their parents is seriously restricted—in some cases, the mental health crisis might be the result of chaotic family circumstances at home or ill treatment—or where the wishes of the young person conflict with the wishes of the adult.

Every in-patient child or young person should have a personalised care plan that includes their views and wishes and access to an advocate. They should be regarded as a child in need under the Children Act 1989 so that parents can ask for help from their local authority.

As the British Medical Association lead for mental health, Dr Andrew Molodynski has said:

“Warehousing unwell people in locked wards far from home goes against the very nature of mental health rehab—to help them reintegrate back into society.”

Unnecessary detention of vulnerable patients is not only unhelpful in terms of their recovery, but an ineffective use of taxpayers’ money. Too much money is being given to private firms to look after people with serious mental health problems in units often hundreds of miles away from their homes due to a shortage of NHS beds. That figure was £158 million in 2016-17 and £181 million in 2017-18—an increase of £23 million.

Last year, an extensive study of mental health rehabilitation by the Care Quality Commission found that stays in private beds cost twice as much as in the NHS because they tend to last twice as long. It found that the annual cost of rehab was £535 million and that private beds were on average 30 miles away from patients’ homes, whereas in the NHS they are only nine miles away.

One of the cases that I have been dealing with recently is that of a child who is in a mental health unit 150 miles away from home, but the unit closest to her home is in special measures and not accepting new patients. However, the unit she is in is ranked as outstanding and she seems to be making good progress. Clearly, when parents are faced with such a choice, they want their child to go to the best unit possible, but that can put huge pressures on a family, in particular when they have other children, as well as jobs and lives. They might also not have the money to decamp to somewhere so they can visit their distressed child each day. There is a real lack of support in the system for families placed in such circumstances, with their whole lives disrupted by trying to be in two places at once.

Another problem is that the quality of care in hospitals can be highly variable. The Whorlton Hall case demonstrated just how awful situations can be, and how badly people can be treated in some places. In a recent investigation into children with learning disabilities or autism living in mental health hospitals, some families told the Children’s Commissioner about the excellent support that their children had received—it is important to put on the record that there is good care out there—but others had shocking stories to tell. For example, one family said that their son had not been washed for six months while in hospital. Basic care needs were not being met.

Despite improvements in recent years and the drive towards parity of esteem between physical and mental health services, it has not been realised. The aspiration is noble and shared by both parties, but we need to invest far more in our mental health services for people to get the support they need. I welcome the fact that the need for better community services was highlighted in the recent NHS long-term plan, and I am pleased that the Government have committed more funding to severe mental illness and to greater use of alternative mental health crisis provision, such as crisis cafés. However, an overhaul of the Mental Health Act is clearly needed if that investment is to be used in the best interests of patients by ensuring that their dignity and rights are protected and that they are treated in hospital only as a last resort.

The previous Prime Minister committed to new legislation to bring the Mental Health Act into line with a more modern understanding of how best to treat mental health. She confirmed that a White Paper would be published before the end of the year. The Minister is probably wondering whether she will be in post by the end of today, but even if she is moved on to greater things, I hope she asks the new Prime Minister to give that the same priority as the previous Prime Minister did.

--- Later in debate ---

[Jackie Doyle-Price]

That is an excellent point, and it plays into a general prejudice that people who are in detention are just an inconvenience to be managed. In the context of Sir Simon’s review, the whole ethos that any reform we make should be about empowering patients brings with it obligations to challenge other aspects of the system, not just the care providers. The hon. Lady is right to say that I need to take that up with the Policing Minister, which I will do as part of rolling out our preparations for the White Paper. I understand the hon. Lady’s lack of confidence when I say that the White Paper can be expected before the end of the year, but that is certainly my ambition, notwithstanding the fact that I know she has been waiting rather a long time for another paper that she was promised.

I can reassure the hon. Lady on the extent of the work that Sir Simon has done and the engagement we have had, especially with service users. Rather like the hon. Member for Bermondsey and Old Southwark, those service users shared with us their personal experiences, often reliving significant distress. Given that they have participated and that we have raised their expectations, we would, to be frank, be letting them down if we did not address that. I do not think that would be in any way forgivable, so, as long as it is on my watch, we will be pushing ahead.

As the hon. Member for Bermondsey and Old Southwark said, we are dealing with legislation passed in 1983, so although this appears to be a once-in-a-generation opportunity to reform this legislation, I hope that that is not the case. The situation is probably more symptomatic of the fact that we have not given this matter as much attention as it deserves, but clearly that has changed. The world has changed in terms of how we debate mental health, and that is welcome. Chiming in with the discussion we have had today, I am keen that we take this matter forward with consensus.

I pay tribute to the leadership that Sir Simon has shown in this review. As well as not ducking the controversial aspects of examining the legislation, he has engaged in dialogue and dealt with them in such a way that it is accepted that Members, peers, service users and professionals need to consider them. I am incredibly grateful for what he has done.

We talk more about mental ill health now, but when it comes to severe mental illness—the hon. Member for Bermondsey and Old Southwark spoke about schizophrenia —that is something that reveals incredible prejudice in people. As we have heard, if someone is able to manage their condition, they can live a full and independent life, but the key is being able to manage the condition with the appropriate support. We still have a lot to do in educating the public and society about the real impact of severe mental illness.

There are so many issues, but I will try to address them all in the time I have. The hon. Member for Bristol East (Kerry McCarthy) asked about out-of-area placements for people with autism and learning disabilities. I must say that this is something that really bothers me. Far too many people remain in institutional care and in out-of-area placements, and nowhere is that more true than in the field of learning disabilities and autism.

It is interesting, once we dig under the issue, to see that we have been very successful in getting people with learning disabilities out of in-patient care and into the community. However, that has been matched by a bigger increase in the number of people with autism finding their way into in-patient care. That tells me—I do not think this will be a surprise to anyone in the Chamber—that we are not doing enough to diagnose autism early enough, and as a consequence we are not equipping people with the skills to be able to live independently.

The ultimate result is that we end up putting people in in-patient care. Quite often, those people are forgotten about and it becomes very expensive to keep them there, so not only are we failing people by not having services for them early enough, but we are adding significant cost to the taxpayer and, frankly, doing harm, because the longer those people stay in in-patient care, the more their ability to live independently diminishes. As far as I am concerned, that is a major failing that we need to address.

[Kerry McCarthy]

I thank the Minister for that. There are two aspects that I have come across. First, it is often when a child reaches their teenage years, which we know are difficult for any child with all the turmoil that is going on physically and mentally, that the anxiety takes over and they eventually go into crisis, and things that perhaps should have been picked up sooner are only picked up then. Secondly, that seems to be particularly true for girls. We know that it is more difficult to diagnose girls with autism than to diagnose boys. I was told yesterday, although I do not know whether this figure is true, that one in four girls in mental health units with anorexia is diagnosed with autism. There is a lot of work to be done in the early years, before they reach that crisis point in their teens.

[Jackie Doyle-Price]

I agree with every word that the hon. Lady says. One of our expectations of the new mental health support teams that we are rolling out into schools is that they will be able to work with schools and to spot people who might be in trouble. She is right that, with girls particularly, autism is under-diagnosed, and by the time the challenges start to have an impact on mental health, it is much more difficult to give people appropriate support. Early diagnosis is key.

I am pleased that we are now setting up a unit within the Department of Health and Social Care to look at neurodiverse conditions and what more we can do to improve service provision for them. I am also pleased that NHS England shares my concern about this and that we can expect more work on it, but there remains a lot to do and I do not shirk from admitting that.

--- Later in debate ---

[Jackie Doyle-Price]

I cannot commit to delivering that, but I can commit to looking at it. I hope that is good enough for the hon. Gentleman.

[Kerry McCarthy]

In the case that I was talking about, the problem was not just that the treatment was so specialised that it was that far away, but that that was when the bed became available. It is a bit of a lottery. The one closest to home was not taking in new patients because it was in special measures. There would have been other places closer. If the person does not accept a bed when one becomes available, they may have to look after a distressed child for an awful lot longer.

[Jackie Doyle-Price]

This comes back to housing. One challenge is getting access to a bed, and another is when the person comes to leave, because we need to discharge people into safe living environments. Are there enough supported housing solutions? No, not always, so the bed remains full. I am having conversations with colleagues in local government to see what more we can do to deliver more supported housing so we can get the pathway going. We could fix it by making more beds available, but that is not really the answer. I am concerned that the longer we leave people in in-patient care, the more harm we do. We have to get that movement through the system. Hopefully, if we do that, people will be less likely to grab the first bed because they can be confident that more will become available more frequently. That is where we need to get to. I appreciate that right now it feels desperate.

There is an issue with quality. The Care Quality Commission has a challenge in deciding whether more harm will be done by taking enforcement action on a place rather than working with it to improve. We see that writ large in TV programmes such as “Panorama”. There is a massive disparity in the quality of care. I challenge the CQC to be a lot more aggressive when we see poor standards of care.

The hon. Member for Bristol East mentioned private providers. People have heard of The Priory. They hear that celebrities go there and they think it is a centre of excellence. The truth is that the care there is less than optimal, but someone with a loved one who needs hospital treatment will not know that. We need the CQC to have a lot more teeth in terms of improving what comes out of its inspections. The system generally needs to support it in doing that.