Mental Health Act 1983

Lord Beamish Excerpts

Thursday 25th July 2019 Westminster Hall

[Neil Coyle]

I absolutely agree and will come on to some of those figures.

I referred to the children in Southwark who have mental health conditions. The NHS’s overall target for ensuring that children and adolescents can access mental health treatment is just 35%. That is remarkably low, and I hope the Minister will have something to say about it today. In the meantime, while that is the national standard, Southwark’s Labour council has set an ambition to ensure that 100% of children and adolescents can have access to mental health care. As part of that commitment, the council has made £2 million available for local schools to support the emotional wellbeing and mental health of pupils. It is also developing a mental health hub service for young people. That is in partnership with—jointly funded by—the local clinical commissioning group.

As I have said, I think that my personal experience has given me an additional strength in working with local people and families who are affected by these issues, but being open about my family experience does not mean that I have not seen discrimination or stigma at first hand. I was about 10 or 11 when I said to a friend at school that Mum had schizophrenia and he asked whether that meant I had two mums. That was a surprising reply, but obviously there was a lot of confusion then about what schizophrenia actually was. Some of it is still out there.

Sadly, one thing that remains is the perception that people with schizophrenia are somehow more dangerous. Actually, mum’s experience and that of many people with schizophrenia is that they are more likely to be targeted, because their erratic behaviour when they are unwell can draw the attention of others, who might target them for robbery and other offences.

[Mr Kevan Jones (North Durham) (Lab)]

I thank my hon. Friend for the way in which he is opening the debate and particularly for his comments on schizophrenia. If they have the right support, there is no reason why anyone with schizophrenia should not live a normal life, including being able to work.

[Neil Coyle]

I completely agree. Sadly, the figure for people with schizophrenia in work remains at about 5%. It is just 5%, because the support simply is not there and the medication and treatment are not there on a routine basis to ensure that they are able to work.

Figures suggest that one in four of us will experience mental ill health at some point in life, often because of bereavement or a relationship breakdown. I pay tribute to all the organisations involved in the Time To Change campaign, which has done brilliant work to challenge the stigma and discrimination that affect people with mental health conditions in employment and elsewhere.

The change in language and awareness of conditions is one reason to seek reform now. For example, the Mental Health Act 1983 is defined as:

“An Act to consolidate the law relating to mentally disordered persons.”

The language around mental health has changed much since the current law was enacted. We also need to consider its far reaching powers.

The independent review of the Mental Health Act, published seven months ago concluded:

“The Mental Health Act gives the state what are amongst the most significant powers that it has; the power to take away someone’s liberty without the commission of a criminal offence and the power to treat that person even in the face of their refusal. Because of that, we think that is important that the purpose of the powers is clear, as should be the basis on which they should be used.”

It is hard to disagree with that conclusion, especially given the number of people who are affected by those extensive powers.

--- Later in debate ---

[Mr Kevan Jones (North Durham) (Lab)]

It is a pleasure to serve under your chairmanship, Ms Buck. I put on record my thanks to my hon. Friend the Member for Bermondsey and Old Southwark (Neil Coyle) not only for securing the debate but for the way in which he introduced it. I agree with the hon. Member for Plymouth, Moor View (Johnny Mercer) that someone speaking so powerfully brings to life what might be dry words on paper in an Act. To hear the experience that my hon. Friend and his family have been through highlights why it is important that we get things right.

My hon. Friend described how the Mental Health Act 1983 gives the state draconian powers to detain individuals and take away their liberty, not because they have done anything wrong but because they are mentally ill. As he said, 50,000 of our fellow citizens go through that process every year. There is something wrong if we are using the Act 50,000 times a year. I am sorry, but I just do not accept that in 2019 that is the only way we can deal with someone in mental health crisis who, rather than being a danger to anybody else, is possibly more of a danger to themselves.

Like others, I accept and welcome Professor Simon Wessely’s report. As my hon. Friend said, some of us remember the 1983 general election. It was a long time ago, but there are some similarities, as he said, with the current political world. Importantly, things have changed, including our attitudes on a whole range of things. The key issue that comes out of Sir Simon Wessely’s report is the need to put the individual at the centre of everything. The hon. Member for Plymouth, Moor View gave a very good example of how, when we get it wrong and do not put the individual at the centre, things are bad for that individual. Clearly, his constituent was treated inhumanely. We must put people at the centre. That is difficult, as people who are in mental health crisis can have great difficulty in making decisions, but that does not mean that they have lost capacity in all circumstances. That is one of the things that Sir Simon raised in the report.

The use of the Act should be a last resort, not the first course of action in dealing with people who are in mental health crisis. As the report says, we also need to involve the individual in decision making. That can be difficult; I accept that people can refuse treatment. However, if it is properly explained and people are involved in the decision, there are better outcomes for them individually and in-patient time will be reduced.

I have spoken before about advocacy. Owing to the draconian powers that the Act bestows on the state, it is important that the individual has access to independent advocacy. I welcome the recommendation for people to have to opt out of having an advocate. That puts the onus on the state to have independent advocates trained and available, and to ensure that people know how to access them.

My hon. Friend the Member for Bermondsey and Old Southwark also raised the issue of family members, which can be very difficult. The report’s suggestion to move towards having a nominated person is the way forward. In the past, assumptions have been made that an individual wants certain relatives involved; on a number of occasions they do not want that, and it may not be in their best interests. The right hon. Member for New Forest East (Dr Lewis) made the point that we need to try to involve family members where we can, because they are an important part of supporting the individual and ensuring that they get the help they require.

I am concerned about a lot of issues related to the Act, including the need for a timetable for implementing the recommendations. A White Paper has been promised. I do not criticise the Minister because, as I have said before, since she has been in post she has been a strong advocate for mental health issues. However, this matter has to be a priority. I know we can get blindsided by big issues regarding Brexit, but the implementation of these changes is important and should be a top priority.

The report states that we need to investigate why the Mental Health Act is used more against members of black, Asian and minority ethnic communities than others. I accept that there may be a stigma attached to mental health issues in certain BAME communities and that it might give rise to particular questions, but that topic needs an inquiry all of its own. Unless we get answers to why the Act is being used more in those communities, we will not be able to make the necessary changes.

Why is the Act being used more? Perhaps there is a simple answer. Ever since we closed the asylums in the early 1980s, we have put neither the investment nor the policy in place to support people with long-term enduring mental health conditions in the community. That is about money to pay for the support that individuals need, but it is also—my hon. Friend the Member for Bristol East (Kerry McCarthy) raised this point—about pathways, how people get into the system, and the disconnect between the various agencies with which people come into contact.

The all-party parliamentary group on social work has just conducted an inquiry on that subject. I am not going to steal the thunder of my hon. Friend the Member for Stockton North (Alex Cunningham), who chaired the inquiry. It was very informative, and I was privileged to be involved in it. The disconnection and lack of integration between local councils and the health service is clearly an issue, and it is not necessarily just down to money; it is also to attitudes. The system needs to be put back together. It is no good telling somebody who is in a mental health crisis, “I’m sorry, but you are not my responsibility; that is a local authority issue,” if they present to the NHS or vice versa. That needs to be put right.

In County Durham we have a very good integrated system of local government and NHS care, which works very well. If we are to put that wraparound care around individuals such as the mother of my hon. Friend the Member for Bermondsey and Old Southwark, it must be integrated; it must be joined up. It cannot be fragmented.

Is the problem all about the availability of beds? I would say no, it is not. The right hon. Member for New Forest East is right that we have cut beds back too quickly, thinking that we do not need them and that we can manage people in the community when we cannot. The argument that follows is, “The answer to this is more beds.” Well, I am sorry, I do not think it is, personally. What I want is a good community-based model to support people in the community. That is going to take money. It needs a clear, worked-through policy. It has to include local authorities and it has to include housing. One of the biggest issues that people leaving in-patient beds face is the question of where they will live, and it is not surprising that many of them end up on the streets in our communities. We need a joined-up approach.

As I said earlier this week in another debate on mental health, we must have a joined-up local system that includes not just the agencies I have mentioned, but the community and voluntary sector. If we are going to support people in the community, in my experience it is often best done by voluntary and community sector organisations. As my hon. Friend the Member for Bermondsey and Old Southwark said at the beginning of the debate, many of those organisations are under pressure because grants are being cut. We need a joined-up approach.

While I am on my hobby horse about the voluntary and community sector, can such organisations bid for contracts from clinical commissioning groups and local authorities? In many cases they cannot, because they are not big enough. The contracts are drawn up in such a way that they are not available to those organisations. In terms of value for money and local input, that would be very important.

We must also support and develop staff in the sector. During the inquiry, we met some amazing, inspiring young people who were entering social work and majoring in support for people with mental health issues. In Durham a few weeks ago, I had the privilege of meeting some of the young people who were taking part in the Think Ahead programme—I think it was started by one of the Minister’s predecessors—which aims to get social workers trained in mental health work. Most of those I met said it was a very rewarding field to get into, when it was properly supported.

What about other Government policies? We need joined-up policy at the local level to support individuals, but we also need to make sure that mental health is hardwired into Government policy. I have said that on a number of occasions, and I will do so again. For example, if someone in the community has a long-term mental health condition, fails her personal independence payment assessment and is sectioned—I handled a similar situation a few weeks ago—what does that cost the taxpayer? It is no good for the individual and it is no good for the taxpayer. Under mandatory reconsideration, the PIP was reinstated. We have to make sure that consideration of mental health issues is built into policy and that the policies of other Government Departments are not creating problems for individuals.

Finally, as we know, many individuals in prison have mental health problems. The current system for transferring individuals from prison to mental health facilities is not working. That is another issue that I have raised previously. Those on indeterminate or fixed sentences who come up for assessment by the Parole Board face a double jeopardy situation. They have to have a mental health assessment by both a mental health tribunal and a Parole Board. That cannot be right. It leads to, on average, an extra 18 months in prison, where proper treatment and proper planning is difficult. It does not help them or the system, and it costs more to keep them in prison. We need a system where one single assessment would be enough to make sure that those people get the support they require.

This is about money and it is about reforming the existing system, but we must also ensure that both national and local policies enable a joined-up, wraparound service. With the right investment and the right political will, we can get there. We are not going to go back to putting people in institutions or asylums; people should be able to live a happy, contented and safe life in the community, with the wraparound care that they deserve. That is what we should be providing, as a decent society.

--- Later in debate ---

[Alex Cunningham (Stockton North) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Hanson, and to follow not just the contribution from my hon. Friend the Member for Croydon North (Mr Reed), but the other speeches. Great expertise and understanding has been brought to the debate. I congratulate my hon. Friend the Member for Bermondsey and Old Southwark (Neil Coyle) on securing the debate, and I thank him for sharing a very powerful and personal testimony as well as offering solutions to the crisis in mental health. So often we can blather away in places such as here in Westminster Hall; we can talk about the problems, issues and suffering, but sometimes we do not offer solutions. It is our job to come up with solutions, and my hon. Friend the Member for Bermondsey and Old Southwark and others have offered some.

As some colleagues might know, I have the privilege of chairing the all-party parliamentary group on social work. As my right hon. Friend the Member for North Durham (Mr Jones) said, we recently undertook an inquiry on the role that social workers play in upholding the principles outlined in the independent review of the Mental Health Act 1983, and on how that role can be recognised and enhanced in new legislation.

I believe that social workers are regularly, if not always, undervalued, yet their work is incredibly valuable in supporting and helping the most vulnerable people in our society—be it children at risk, older people in need of a bit more support, or families who experience breakdown and need the independent support that a social worker can provide. Of course, social workers also support people with mental health needs, although many people do not realise the tremendous role that they play in that. They ensure that mental health problems are not a barrier to anybody achieving the things they want, and that people get the appropriate treatment and care that they need.

Back in 2018, I met with two approved mental health professionals in my role as the chair of the APPG on social work. They are known as AMHPs—perhaps it is something to do with their electrifying personalities. They explained that there was a need to promote the role of social workers in mental health services, and I now understand why that is necessary. The legislation and policy often skim over the work of social workers, perhaps because it is so varied and hard to pin down.

In December, the independent review of the Mental Health Act 1983 published its report and recommendations. In preparation for a Government response, the APPG decided to have our own inquiry and add to that great piece of work. Some 9,000 social workers work in a defined mental health role, accounting for about 4% or 5% of the core mental health workforce, and 95% of AMHPs are social workers. I know it will take more than legislation to embed the kind of changes we would like to see, and work will have to be done by CCGs, local authorities, the NHS and social work leadership—to name but a few—if we are to succeed and get the change that is needed. I am hopeful that the APPG’s report and recommendations will act as a staging post on the way to cultural and legislative change.

[Mr Kevan Jones]

Was my hon. Friend impressed, as I was, when we met various people giving evidence to the inquiry? The best practice was where local authorities and the NHS were co-located and working closely together, rather than when it was being divided.

[Alex Cunningham]

Yes, that was most certainly the case. I shall remark on that a little later in my speech. I was really concerned to find that the number of joint working arrangements was diminishing rather than increasing across the country, but I will address that a little later.

I was surprised to hear in the evidence sessions that health and social care integration, which the Government are officially pursuing, is going backwards. My right hon. Friend spoke about that in detail. A key message from the APPG is that the Government need to urgently examine how they can better support the integration programme, arrest the decline and ensure that people work together. Social workers in health and in local authorities need to work much more closely together.

Integration in mental health services is about bringing the social mode into healthcare settings, where social approaches sometimes struggle to gain acceptance and respect when compared with the medical model. We do not suggest replacing one with the other but, as integration implies, a full marriage of the two models so that the needs of the individual are met in one place. Better still, a properly integrated social model would make sure that treatment and care planning were guided by the person in their own context, rather than fitting them into a pre-existing diagnostic box. Such an approach means greater consideration of the social determinants of mental ill health—factors such as socio-economic background, education, housing and family dynamics. We have heard examples of that throughout the debate.

The APPG report made several recommendations. The new mental health legislation should open with a definition of the social model and the importance of addressing the social determinants of mental illness alongside biological and psychological determinants; it should explicitly name social workers as the key professionals doing the work; Ministers should ensure that the team preparing new mental health legislation also produces guidance on how it is intended to interact with other legislation such as the Mental Capacity Act 2005 and the Equality Act 2010; the CQC should be mandated to provide an annual report to Parliament on the progress of health and social care integration; and social work leadership—this is particularly important—on trust and CCG boards is necessary. I think it is more than necessary; it is essential. They are professional people with a major and specific role and they should be at the table where the decisions are made.

The report also recommended that new mental health legislation must have greater regard to both health and local authority resources. My right hon. Friend the Member for North Durham talked about the lack of resources within the system. CCGs should be held transparently accountable for their duties under section 140 of the current Mental Health Act, or any new legislation, making sure that there are enough beds in the right places. The people detained under section 3 of the Mental Health Act should be reviewed by a social worker, and families and carers of all people detained away from home because of a lack of local provision should be provided with financial support. That point was raised by my hon. Friend the Member for Bristol East (Kerry McCarthy), who talked about the effect that it can have on families when a family member in crisis is 150 miles or more away. A national dataset on the number of Mental Health Act assessments should be established as part of the DHSC mental health services dataset. Those recommendations are not unreasonable. I hope that the Department for Health and Social Care will take note and address the gaps where professionals say that they are.

I recently had the opportunity to serve on the Bill Committee for the Mental Capacity (Amendment) Bill, and key issues that I and other colleagues raised still need to be looked at. During the passage of that Bill, I was quite surprised to find out that the Bill had not been subjected to any pre-legislative scrutiny, despite its central role of redeveloping the laws of this country for depriving people of their liberty. I said that I thought the Government needed to pause and think again about the implications of the plans that Ministers were putting before us, listen to the countless charities, other organisations and professionals who work with the legislation every day, and come back with a Bill fit for purpose. It should not have been about a basic political argument between the Government and the Opposition. It is about a debate between the law makers and the people, some of whom at a particular time in their life can be subject to some of the most restrictive legislation that we have. Sadly, at that time the Minister did not listen, and the legislation we are left with will need to be reviewed before too long. I feel the same about moving forward with reviewing our legislation in general around mental health, and perhaps putting new legislation to this House, but whatever it is, it needs to reflect wide views.

The legislation that we create or amend affects the most vulnerable in our society, as I have said before, but it should be considered with extra care and attention. I do not think that we did that in the recent Bill Committee, so we must include those who know what they are talking about, such as the professionals, the experts and the social workers—those who have worked on the frontline of mental health care and know where the gaps are and how we can ensure that we do better for those who receive care under mental health provision. We must and can do better. I hope that as we move forward, Ministers will listen and get it right.

[Barbara Keeley (Worsley and Eccles South) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Hanson, as it was to serve under Ms Buck earlier. I join others in congratulating my hon. Friend the Member for Bermondsey and Old Southwark (Neil Coyle) on securing this debate and echo their comments about the moving way in which he opened the debate. He started with his own family experience and then made a very powerful speech. I am sorry that you missed it, Mr Hanson. We heard contributions from the right hon. Member for New Forest East (Dr Lewis) and the hon. Member for Plymouth, Moor View (Johnny Mercer), as well as my right hon. Friend the Member for North Durham (Mr Jones) and my hon. Friends the Members for Bristol East (Kerry McCarthy) and for Stockton North (Alex Cunningham). I am sure we all want to thank Sir Simon Wessely and his team for their work in reviewing the Mental Health Act.

The wide range of perspectives in the debate is welcome. It shows how wide-ranging the work is and how it touches on so many different aspects. One thing on which we can all agree is that the current Mental Health Act is not working. It is too often overly restrictive and fails to give people the support they need, as we have heard. Before I discuss the contents of the review, I want to mention why it is so important that we get this right, because being detained under the Mental Health Act, although it is sometimes life-saving, can be immensely damaging if it goes wrong, and we have heard already about how it can go wrong. I, too, am going to talk about a case: the case of Matthew Leahy.

On 7 November 2012, Matthew was admitted to a mental health hospital under the Mental Health Act. On 15 November, he hanged himself in his room at the hospital. The Parliamentary and Health Service Ombudsman has identified failures in Matthew’s care that may have led to his death, but they have taken seven years to come to light. My hon. Friend the Member for Croydon North (Mr Reed) talked about delays. They are exasperating, concerning and impossible for families who have to live with the loss of a loved one. Some of the failures in Matthew’s case were truly shocking. He complained that he had been raped in the mental health hospital. The ombudsman found that had Matthew not phoned the police himself, it is not clear that staff on the unit would have done so. Anyway, the police failed to take action.

My hon. Friend the Member for Bermondsey and Old Southwark referred to the level of sexual assaults on patients—an appalling record, as reported by the CQC. It should be of deep concern to us that that is happening. Staff also failed to act when Matthew reported, and he had physical injuries that could have been caused by rape, which should have been a major cause of concern. It is also deeply concerning that his care plan was falsified and other paperwork was lost. Although he had a care plan for his first 72 hours in the unit, staff produced a fuller care plan only after he died. That that should have happened when he was apparently under the protection of the state is unacceptable. We must ensure that we know what went wrong in his and other cases of death so that we can act to prevent it from recurring.

There have also been issues with the subsequent investigation. The initial report by the NHS partnership contained inaccuracies about how Matthew’s care had been planned. Across the board, the partnership failed to learn the lessons of Matthew’s death, which compounds the tragedy of that young man taking his own life while he was in the care of the state. As my hon. Friend the Member for Croydon North has said, there should be independent investigations of deaths that occur in mental health hospitals. I know that the Minister has been asked before to set up an inquiry into Matthew Leahy’s death. I ask her to commit to doing so now, so that we can learn the lessons from that tragic event and prevent such a thing from happening again.

Sir Simon’s recommendations will not solve every problem with our in-patient mental health services, but the Opposition believe that they would improve them, and would remove many of the major issues with the Mental Health Act. Although we have a little time, we cannot focus on all 154 of the recommendations. I just want to discuss the principles that he felt should be central to the operation of the Act. My hon. Friend the Member for Bermondsey and Old Southwark outlined those four principles in his opening speech.

The first principle is choice and autonomy. Of course, it should go without saying that, wherever possible, we give people control over what is happening to them. I am glad that the Government have committed to introducing advance choice documents. Those will be central to ensuring that people can exercise choice over what happens to them. We have heard in many of today’s speeches why that is important. I ask the Minister to confirm today, if she can, when those plans will be brought forward. There will be instances when people cannot exercise the choice themselves, so Sir Simon’s proposals for the new nominated person role and increased use of advocates will ensure that in those circumstances people are still able to influence their care.

During the passage of the Mental Capacity Act 2019 there was a great deal of discussion, involving my hon. Friend the Member for Stockton North, about advocacy. We must ensure that local authorities are fully funded to provide those vital services. It would be a travesty if someone were denied a voice because of budget constraints at their local council. Can the Minister tell us whether the Government will provide additional funding for advocacy to ensure that that does not happen?

The second principle is that of least restriction. It seems self-evident that we should try to ensure that people retain as much of their freedom as possible, but we have heard of the number of ways in which that does not happen. It might mean supporting people to enter mental health hospitals voluntarily rather than their being detained, or ending the use of seclusion and segregation and the terrible cases of restraint that we heard about.

The third principle is therapeutic benefit. Again, it should be self-evident that everything done under the Mental Health Act should be clearly aimed at helping the person in question to recover. If it is not, what is the justification for detaining them? My hon. Friend the Member for Bristol East talked about people with autism and learning difficulties in mental health hospitals, and we have to question how often their detention for periods of five years, or five and a half years, helps them at all, and whether any of what happens to them could be talked about as treatment.

Finally, Sir Simon emphasised the importance of treating the person as an individual. In particular, that section of the review focused on the current experiences of young people and people from BAME communities in mental health facilities. We have heard about that in speeches today. My hon. Friend the Member for Bristol East talked about the lack of support for families of children with out-of-area placements. Sir Simon recommends that, while those still exist—my party pledges to do away with them—financial assistance should be available when a young person is admitted to a placement away from their family. We are committed to ending inappropriate out-of-area placements, but my hon. Friend the Member for Bristol East talked about a case where, if a facility was the only one that would be able to provide the care, a parent would choose it. However, that support and financial assistance must be available. It is not right to cut off a young person’s support network when they need it most.

My right hon. Friend the Member for North Durham also talked about why the powers under the Act are being used more with people from BAME communities, and we must focus relentlessly on the facts.

[Mr Kevan Jones]

Does my hon. Friend agree that we cannot leave the matter where it is? We need an inquiry into it. Sir Simon calls for more research, but unless we have an inquiry we will not be able to get the policy changes to identify what is, clearly, going wrong.