Mental Health Act Reform

Lord Bethell Excerpts

Monday 18th January 2021 Lords Chamber

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

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

The original legislation is 40 years old now and out of date.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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[The Deputy Speaker (Lord Russell of Liverpool) (CB)]

We now come to the 20 minutes allocated to Back-Bench questions. I ask that questions and answers be brief so that I can call the maximum number of the 15 remaining speakers on the list.

[Baroness Hollins (CB) [V]]

My Lords, I welcome the focus of the consultation and the White Paper on prevention, along with the new duties on local commissioners to ensure that they understand and monitor the risk of crisis for individuals—for example, when a family member dies—and to ensure an adequate supply of community services for people with learning disabilities and autistic people as an alternative to admission. Does the Minister agree that for these duties to have teeth, the descriptor “adequate” will have to be defined and subject to legal enforcement?

[Lord Bethell (Con)]

The noble Baroness asks a very perceptive question. I pay tribute to her work in this area and the challenge and scrutiny that she has given to the Government, which have helped lead to the position we are in at the moment. This is exactly the kind of area that we will be presenting for consultation, and I very much look forward to the noble Baroness’s contribution to that consultation.

[Lord Holmes of Richmond (Con) [V]]

I welcome the White Paper, which represents a once-in-a-generation opportunity. Allied to that, can the Minister confirm whether the Government will commit to prioritising permanent and immediate mental health support for all our NHS front-line workers in ICU, in the emergency room and beyond—immediate lifelong prioritised mental health support for all those who have given so much support and continue to give it to all of us through this pandemic?

[Lord Bethell (Con)]

My Lords, I live opposite University College Hospital. Every night I hear the ambulances arriving and I think of the staff on the front line working so hard night after night in such difficult circumstances, dealing with people in agony. The mental health of our NHS staff is paramount. Some £50 million has been invested in strengthening mental health support for staff. We have put in place the mental health hotline, practical support, financial advice and specialist bereavement and psychological support. I have no doubt that more could be done but this is very much an area that, as my noble friend rightly points out, is worthy of more investment.

[The Lord Bishop of Bristol [V]]

My Lords, I join fellow Members in welcoming the Statement and the response to the significant report by Sir Simon Wessely. As the noble Baroness, Lady Thornton, noted and as the Minister commented, the evidence is that minority ethnic individuals are 40% more likely than white Britons to come into contact with mental health services through the criminal justice system. Will the Minister explain how the proposed framework will address the underlying attitudes and practices that led to this statistic, which at best are described as a failure to understand the culture and at worst are a reflection of racist views?

[Lord Bethell (Con)]

The right reverend Prelate is right to allude to the importance of culture. No amount of bureaucracy or guideline-writing can ultimately address the basic attitudes, backgrounds and mental starting point of those involved in these decisions. I reassure the House that at the moment we are processing the people plan, which addresses at a fundamental level the hierarchy, racism, homophobia and misogyny sometimes found in some parts of the NHS. We are acutely aware that culture is fundamental to the safe provision of services to patients. The framework itself is not wholly directed at culture, but it will be supplemented by these kinds of reforms.

[Lord Winston (Lab) [V]]

I congratulate the Government on getting Sir Simon Wessely to help them bring about this much-needed reform and will welcome seeing how it progresses in the next year. I want to draw attention to one of the problems about sectioning patients. Two members of my team at different times have been sectioned; both were psychotic and severely depressed at the time. One phoned me at 5 am to say that people had come for her; it was clear that this was highly scary and very damaging. The other patient was left in a police station after being found on a moor for many hours before eventually a bed could be found, miles from where she lived or where anybody could visit her. Also, the premises available for such patients when they have been sectioned seem quite inadequate. The Minister has mentioned the dormitory system, but when I visited both those women, I felt that I would be very depressed myself if I were in those circumstances. We need to do much more to make premises more homely if we are to be more successful in encouraging a return to normal health.

[Lord Bethell (Con)]

The noble Lord is entirely right: when people experience a mental health crisis, they should be treated with consideration. Unfortunately, the police are sometimes at the front line of dealing with those with mental health difficulties. It is a stretch for them, and they should have the right training to be able to deal with a situation sensitively and they should have the right premises to be able to give people safe and secure environments. It is at the outer limits of their professional responsibilities, but we are doing as much as we can to put the training in place.

I remember from my own personal experience, when my father and my mother were sectioned, the consideration and thoughtfulness of those involved in both those processes. It is not all bad, but I take the noble Lord’s point.

[Baroness Jolly (LD) [V]]

My Lords, I welcome the White Paper and the commitment to deliver person-centred care. Many health and social care professionals will need to change the way they work, which is both necessary and welcome. What is the national budget for training over the next five years and how soon will those being treated for mental health conditions expect to notice a difference in their care?

[Lord Bethell (Con)]

My Lords, the noble Baroness is entirely right: the training is critical in this area; it could not be more important. We have invested £500 million in mental health services and support for the NHS workforce to address this. I cannot give her the precise number that she has asked for, but I shall write to her if I can track it down. However, we recognise the urgency of the situation and we hope that the impact of this money will be felt as quickly as possible.

[Baroness Meacher (CB) [V]]

My Lords, I too welcome this White Paper based on the Wessely review. However, without real increases in spending on mental health, the anticipated Bill will not be able to fulfil its potential. I was not reassured by the Minister’s comments on funding.

If we become physically ill, we can expect to be treated within a reasonable timeframe; that is not so in mental health. If the Minister agrees that that is not acceptable, will he challenge the £2.3 billion figure, which, as I am sure he knows, will do nothing to rectify the ongoing imbalance and will leave people detained in hospital because of the absence of adequate community services?

--- Later in debate ---

[Lord Bethell (Con)]

My Lords, the noble Baroness is right that community support for those with mental health challenges is critical—we are supporting community health in addition—but I slightly disagree that the £2.3 billion will make no difference. It is a phenomenal commitment and it demonstrates that the Government have recognised that mental health services have lagged behind primary care and physical services, as the noble Baroness rightly points out, and we are working hard to make up the difference.

[Baroness Sanderson of Welton (Con) [V]]

My Lords, I too welcome the White Paper and in particular one of its key aims, which is to address the disparities that exist in relation to those from black, Asian and minority-ethnic backgrounds. The data from the race disparity audit played an important role in revealing those disparities. Can my noble friend the Minister confirm that the Government will continue to utilise the work of the Race Disparity Unit as we continue on the path towards the first new mental health Bill in 30 years?

[Lord Bethell (Con)]

My Lords, I have met the Race Disparity Unit and can share my noble friend’s testimony to the critical work that it does. The statistical collections managed by NHS Digital have shone a light on the extent of the disparities illustrated by Sir Simon, most notably that black people are more than 10 times more likely to be made subject to a community treatment order after discharge from hospital. That is an astounding number. We are determined to take action; we will introduce a new patient and carer race equality framework which will support NHS mental health care providers to work with their local communities to improve the ways in which patients access and experience treatment. The Race Disparity Unit will continue to play a key role.

[Lord Bradley (Lab) [V]]

My Lords, while I welcome the White Paper, it is unlikely that the legislation will be enacted until 2023. Many reforms can be made before that date to implement some of Sir Simon’s recommendations, including the development of community facilities to support people with learning disabilities and autism so as to hugely reduce the use of in-patient beds and, crucially, alternative provision to finally stop the use of prison and police custody suites as places of safety. I therefore press the Minister again to assure the House that sufficient capital funds are available within the NHS long-term plan to implement such key recommendations.

[Lord Bethell (Con)]

The noble Lord is 100% right: we can definitely start work on the recommendations of the report. As I said earlier, we have already done so: committing £400 million to end dormitories in 40 trusts. That sort of parallel processing can be done for other elements of the report. The consultation began last week, which shows our determination to get moving. Some recommendations of the report are spellbindingly obvious; we will work on them immediately. The role of police suites in safe refuge, cited by the noble Lord and by the noble Lord, Lord Winston, is exactly such an example.

[Baroness Barker (LD) [V]]

My Lords, this is yet another NHS document which makes not a single mention of the needs of LGBT people. The Statement is in effect an admission that the Mental Health Act 2007 was deeply flawed and, as a result, thousands of people have been subject to wrongful treatment. Will the Government act now to stop the abuse of community treatment orders and other elements of that Act that have led to the position that is so accurately described by Sir Simon Wessely?

[Lord Bethell (Con)]

My Lords, I confess that the noble Baroness has me on the hop there, because I had not noticed that LGBT issues are not mentioned in Sir Simon’s report. I share the noble Baroness’s surprise about that. Let me return to the document and I will address her point in correspondence.

[Baroness Wheatcroft (CB) [V]]

My Lords, Sir Simon found excessive use of restrictive practices in mental health institutions. Many of us will be familiar with the appalling case of Bethany, the autistic teenager who spent three years in what can be described only as a cell, in an appallingly inhumane regime that kept her locked up in solitary confinement and with no physical contact with other people. Only when her father went to court did she escape, and she is now living happily in an open-plan institution. Can the Minister assure us that such treatment will never be condoned again? We cannot wait for legislation on this.

[Lord Bethell (Con)]

My Lords, I certainly do not condone that treatment in any circumstances, but I acknowledge the noble Baroness’s point: there have been some instances in the past—reasonably rare but consistent—where those with autism and learning difficulties have been subject to the most inappropriate regimes and where a completely different type of support, therapy and accommodation from the kind found in mental health institutions was needed. The campaign to which the noble Baroness alluded is entirely right and we are moving quickly to address those points.

[Lord Davies of Brixton (Lab) [V]]

My Lords, the White Paper is certainly to be welcomed, as there is much to be done. The number of people being detained in hospital under the current Mental Health Act has increased over the past few years. One reason is the lack of resources to provide the support needed in the community and respite care. While we are told that there has been investment, the resources often do not reach hard-pressed mental health trusts. More resources will be needed, not only to grow the workforce but for the workforce to receive education and training in the values and practices needed to deliver the radical changes envisaged in this review. We should also ensure that the workforce better reflects the communities it serves. Again, while I welcome the promise of further investment in mental health services, will the Minister give a commitment that this will be new money and that it will reach mental health trusts, to provide the workforce growth, and Health Education England, to provide the workforce training essential for delivering the aims of the White Paper?

[Lord Bethell (Con)]

The noble Lord is right; the numbers are inappropriate. Fifty-one thousand detentions under the Act in 2019-20 seems far too many. Detentions under the Act rose by 40% in the 10 years to 2015, and we thought of this Act to try to address that injustice. The £2.3 billion is new money, and it will make a huge impact on the mental health trusts he describes.

[Baroness Sheehan (LD) [V]]

My Lords, sadly, I have personal experience of having to invoke the Mental Health Act. It is a dreadful process. It concerns me that one of the reforms proposed is to tighten the criteria for civil patients’ detention by raising the threshold for risk of harm. Does the Minister agree that this reform risks increasing harm to the person who is ill and their family?

[Lord Bethell (Con)]

My Lords, that is not the intention of the report, and I confess to struggling to understand how that would be the case. I would welcome correspondence from the noble Baroness to detail her concerns so that they can be taken on board.

[The Deputy Speaker (Lord Bates) (Con)]

I call the noble Lord, Lord Singh of Wimbledon. No? Lord Boateng.

[Lord Boateng (Lab) [V]]

My Lords, the Minister is to be commended for calling out racism, because that is what many black and south Asian patients experience. Will he ensure that commissioners in the field, with this new money given to them, fund local, community-based advocacy groups? And will he ensure the health review tribunals reflect the communities on which they are adjudicating and recognise racism in the mental health service?

[Lord Bethell (Con)]

My Lords, the role of health review tribunals is critical, and more needs to be done to ensure that they reflect the communities they represent. I am not sure it is the role of mental health trusts to finance local advocacy groups, but he is right that they make a difference and hold the system to account. The broader issue of racism in the NHS is a cross-institutional challenge that must be addressed by all parts of the NHS, and we are committed to doing so.

[Lord Dodds of Duncairn (DUP) [V]]

My Lords, I warmly welcome the Government’s proposals. A key area of concern for me is the length of time people spend waiting in emergency departments for assessment, even after being referred by their GPs. Will the Government guarantee, as others have mentioned, that sufficient resources in staffing will be made available to ensure that these warmly welcomed reforms are carried out and the quality of care increases?

[Lord Bethell (Con)]

My Lords, I can reassure the noble Lord only by saying we have put an ambitious report on the table. We will follow it up with a detailed consultation process that will engage Parliament in due course and lead to an ambitious Bill. That will be backed by substantial financial investment; thereby, we hope to make a major impact on the issues he describes, which I recognise and acknowledge.

[Lord Adonis (Lab)]

My Lords, Sir Simon’s report makes no reference to international best practice and gives no internationally comparative statistics—for example, on sectioning. I gave the noble Lord notice of a question I would like to ask about what international best practice the Government have in mind. Will he be able to make available to me, perhaps in correspondence, internationally comparative, population-adjusted statistics for sectioning? This will be important for putting the reforms he suggested in context before we proceed to legislation.

[Lord Bethell (Con)]

I am enormously grateful to the noble Lord for sending me his question, but I am embarrassed to say that I did not receive the correspondence. I would love to have the figures to hand, but I will write to him with details. If I could gently push back: this is not an easy issue to make international comparisons on, and we are not necessarily led by what other countries do in this area. We have to own this problem ourselves and find an approach that fits the NHS and people in Britain, and we have to be accountable to the people of Britain for our performance.