Health: Deprivation of Liberty Safeguards

Lord Bradley Excerpts

Monday 16th March 2015 Lords Chamber

[Lord Bradley (Lab)]

My Lords, I congratulate the noble Baroness, Lady Finlay of Llandaff, on securing this short debate and on her excellent speech on the issues of deprivation of liberty safeguards and healthcare, particularly in respect of hospices and homecare support. I also congratulate the noble and learned Lord, Lord Hope, the noble Baroness, Lady Hollins, and the noble Lord, Lord Howard, on their very wise and detailed contributions, particularly around hospice care. This debate effectively complements the debate last week on the excellent Select Committee report on the Mental Capacity Act 2005, when the noble Baroness, Lady Finlay, rightly stated that the laudable principles of the Act have clearly not been realised as was hoped.

The House of Lords Select Committee made nine recommendations that related to deprivation of liberty and the Government responded to them in June 2014. I will return to one or two of them shortly but I want to concentrate in the limited time available on some of the consequences of the Supreme Court judgment. In March 2014 the UK Supreme Court handed down two judgments, which are commonly known as the Cheshire West judgment. As the noble and learned Lord, Lord Hope, has eloquently explained, these judgments outlined the test that must be used in the determination of whether arrangements made for the care and treatment of an individual lacking capacity to consent amount to a deprivation of liberty. As the British Medical Association commented, in its judgment the court said that:

“The benign purposes of care arrangements are not relevant to the question of whether a person was deprived of liberty … What would be a deprivation of liberty for a non-disabled person is also a deprivation for a disabled person … The key feature is whether the person concerned is under continuous supervision and is not free to leave … The person’s compliance or lack of objection, the purpose of the placement or its relative normality are immaterial”.

As a consequence of this judgment there has been a significant increase in the number of DoLS applications received by local councils, as we have already heard. Government figures show that there were 13,000 DoLS applications in 2013-14. Following the judgment, there have been 86,500 applications so far this year, according to the Association of Directors of Social Services. The number of applications has increased every quarter. Further, as ADASS has stated, as well as significant cost implications, this places great strain on the ability of staff and local councils to meet their statutory duties. Most importantly, it makes it harder to meet the needs and protect the best interests of the most vulnerable people in society in a timely way.

I shall illustrate this further. In my council, Manchester City Council, there has been a fivefold increase in DoLS applications since the Cheshire West judgment. In 2013-14, there were 236 applications; this year to date, there have been 1,147 applications. There is also a backlog of 200 cases which the council is working through, having recruited additional assessment capacity. The cost of a straightforward application is £900 in court costs, and court costs will be significantly higher for disputed applications. Therefore, Manchester is experiencing significant cost pressures in court fees and assessment costs to meet the needs of the most vulnerable people and their families. ADASS has suggested that each case needs 10 hours of assessment time. Manchester agrees with that. For Manchester, it equates to 10 full-time equivalent practitioners to deal with the additional assessment requirements following the Supreme Court judgment. To aggregate this, and against a backdrop of considerable strain on resources in adult social care, it is estimated that the cost to councils is in the region of £98 million over and above the current funding for DoLS activity in 2014-15. Furthermore, the BMA has stated that the authorisation for DoLS is cumbersome, bureaucratic and time-consuming and, crucially, will inevitably divert resources from front-line care.

As a consequence, the Local Government Association and ADASS are calling on the Government to fully fund the cost of the changes to DoLS and to ensure that the healthcare of vulnerable people is not affected. I spoke at a Mencap conference in Cardiff today on learning disabilities and access to justice. It expressed concern that the costs imposed by DoLS might deflect from the direct care of people with such disabilities. Will the Minister explain the Government’s position on the funding arrangements?

I return to the Select Committee report and the Government’s response. The House of Lords Select Committee rightly asserted:

“Better understanding of the purpose behind the safeguards is urgently required”.

Part of the Government’s response was to request the health and social care sector to establish a multiagency task force to determine the impact of the Supreme Court judgment on local authorities and to identify potential solutions, such as pooled training and sharing good practice. This is clearly welcome but, as ADASS pointed out, even with extensive sector-led activity, local authorities cannot hope fully to mitigate the impact of the judgment without additional resources. Further, as we have heard, the BMA is calling for an urgent review of DoLS with a view to simplifying and streamlining the system. I would welcome the Minister’s response to that call.

Another key point is that considerable uncertainty remains in a wide range of circumstances about whether care or treatment will amount to a DoLS. This uncertainty could lead to confusion for health professionals and a defensive and bureaucratic mindset, as the BMA pointed out. This is partly through the failure to deliver effective training in this area, as the noble Baroness, Lady Finlay, pointed out in last week’s debate, and can lead to staff being understandably risk-averse in the assessment process.

Investment in training in all aspects of mental health and learning disability legislation and services is essential, particularly in relation to the Mental Capacity Act and the related DoLS. Many organisations support that view, including Mencap, which clearly recognises the specific training needs of staff working with people with learning disabilities. My views on the crucial importance of training, for what they are worth, have been shaped by my involvement in the national rollout of liaison and diversion services for people with mental health and learning disabilities who come into contact with the criminal justice system. Those multiagency programmes rely on training not only within individual organisations but, more importantly, across organisations to ensure that there is a common understanding of the needs of the individual, breaking down organisational and cultural barriers.

While it is welcome that the Government have recognised some of the issues that have been identified as a result of the Cheshire West judgment, faster action and more resources need to be considered properly to respond to the Select Committee’s nine recommendations on goals and to ensure that the health and social care needs of some of the most vulnerable people are properly met. I hope that the Government therefore respond in a more speedy and timely manner on those issues.

Mental Health Services

Lord Bradley Excerpts

Wednesday 25th February 2015 Lords Chamber

[Lord Bradley (Lab)]

My Lords, I, too, congratulate the noble Earl, Lord Listowel, on securing this very important and timely debate on mental health services, particularly for children in care. As we have heard, it has produced many important speeches. I believe that we are at a time when mental health has never been higher on the political and, more importantly, the public agenda. As such, we must all seize the moment. In my brief contribution, I want to remind the House of some key facts that are behind the barriers that may be stopping improvement in mental health services for children, care leavers and, in particular, adolescents.

As we know, mental health problems affect 23% of the population at any one time, and the economic and social cost of mental ill health was estimated in 2009-10 to be £105 billion. As has been pointed out, that is the entire annual National Health Service budget. Furthermore, three-quarters of people with depression receive no treatment at all. That includes children, and 10% of five to 15 year-olds have a mental health problem. This is especially true of children in the care system, who have a poorer level of physical and mental health than their peers and whose long-term outcomes remain worse. Two-thirds of looked-after children have at least one physical health complaint and nearly half have a mental health disorder.

Although the ambition for parity of esteem between mental and physical health is clearly welcome—nothing could be more important in this ambition than children in care—there are concerns that there are major problems in actually achieving it. For example, a recent survey by the Royal College of Nursing revealed that there are now 3,300 fewer posts in mental health nursing and 1,500 fewer beds than in 2010. These problems were further exposed by the Health Select Committee in October 2014, in its report on child and adolescent mental health services. It concludes:

“There are serious and deeply ingrained problems with the commissioning and provision of Children’s and adolescents’ mental health services. These run through the whole system from prevention and early intervention through to inpatient services for the most vulnerable young people”.

That is not surprising given that we know that only 6% of the mental health budget is spent on children and young people in the mental health system and, as has been pointed out, this has been exacerbated by recent cuts in CAMHS services.

Against this backdrop, what needs to be done to improve mental health services, particularly for children in care? First, we need to ensure that there is an adequate number and proper geographical distribution of in-patient beds for all age groups, but particularly for children, when they are required. This should resolve the problem of children being taken hundreds of miles away from home or ending up in adult psychiatric beds, which is totally unacceptable, as the whole House will agree. I know the task force is undertaking this work, and I would be grateful if the Minister could advise us what progress has been made on this issue.

We heard from the noble Lord, Lord Ramsbotham, about the use of police cells and the inaccessibility of proper places of safety. Linked to that, we must ensure that the liaison and diversion programme is completed by 2017. We heard about the expansion of therapy, particularly the IAPT programme, and therapy services for children, which I support, but we must look in particular at transitional arrangements and the ages at which people have access, in a timely way, to those programmes. It is crucial that we recognise the value of early intervention and the dramatic effect on people’s lives, particularly for young people and their families, if that intervention does not take place.

We need a real focus on schools, with all staff, especially teachers, having some level of training in mental health so that they can identity possible issues and passport children to specialist services. We need to look at the Mentally Healthy Society report that was published today, which recognises the need within schools to have a named CAMHS worker for proper link and access. It also recommends training health workers—we have heard a lot about training today—on mental health issues, because, again, they can be crucial in early intervention.

I recently visited a liaison project in Sunderland and met with parents of children who had a mental health problem. The scheme is excellent and the parents are wonderful, but they need tailored, timely and continuous support. Parenting programmes, which are supported by the Royal College of Psychiatrists, need to be expanded and must be funded and developed. Finally, we need a clear strategic commissioning framework to ensure that all relevant agencies—health, criminal justice and others, as well as local authorities, particularly for children in care—work effectively together so that we do far better for all children who have mental health problems.

Autism

Lord Bradley Excerpts

Wednesday 4th February 2015 Lords Chamber

[Earl Howe]

The noble Baroness makes a very good point. That is exactly why we have given clinical commissioning groups new duties to commission services for nought to 25 year-olds and young people to ensure that procedures are in place, to agree a plan of action, to secure provision which meets a child’s or young person’s reasonable health needs in every case, and to work with the local authority to contribute to the local offer of services for children in this position. That is now a statutory duty and I think it is a step forward.

[Lord Bradley (Lab)]

My Lords, the Minister referred to training. Health Education England is one of the bodies charged with delivering the new strategy for transforming care for people with learning disabilities, including autism. Is it not extraordinary, therefore, that it does not keep a record of which universities deliver courses for nurse training in learning disabilities? Will the Minister ensure that such information is available so that training courses are properly monitored, with autism being a key component of such nurse training?

[Earl Howe]

My Lords, the noble Lord makes an extremely good point. I am very happy to take that back with me to the department.

NHS: Dermatology Services

Lord Bradley Excerpts

Wednesday 17th December 2014 Lords Chamber

[Earl Howe]

My Lords, as my noble friend has said, there are clear standards in any referral to treatment situation. That includes dermatology. Where those standards are being breached, we expect commissioners to monitor that and bear down on the failure.

[Lord Bradley (Lab)]

My Lords, I am sure the Minister is aware that the psychological and social impact of skin disease, such as psoriasis, can be devastating. But is he aware of the 2011 survey by Dr Anthony Bewley, which found that of 127 hospitals across the UK only one had a dedicated dermatology psychiatric clinic, only seven had a psychodermatology service, and only one had a children and adolescent psychodermatology service? What action will the Government take significantly to improve psychodermatology services across the country?

[Earl Howe]

I was not aware of that survey but the noble Lord’s point is well made. Guidance for the management of both common and complex skin conditions set out by NICE and NHS England makes it very clear that access to psychological services for patients should be considered where appropriate. Through the IAPT—Improving Access to Psychological Therapies —programme, NHS England is looking at how best to support people with psychological problems arising from their physical problems, including, very significantly, skin conditions.

Hospitals: Voluntary Sector and Emergency Readmissions

Lord Bradley Excerpts

Monday 1st December 2014 Grand Committee

[Lord Bradley (Lab)]

My Lords, I congratulate the noble Baroness on initiating this debate. Although she said that it was put down some time ago, it could not be more timely with the discussions around the health service being so relevant at the present time, and particularly today. So, although there are few us here, as she pointed out, it is a part of a wider debate and conversation about the development of services within the National Health Service.

I have fond memories of the WRVS as a former MP. We were regularly asked to do, and willingly undertook, voluntary work with it in our local hospitals. Often it was one of the most pleasurable days of the year, going round the wards with tea trolleys and seeing day after day the commitment to and enthusiasm for supporting the professionals within that setting and ensuring a high-quality service to patients within those hospitals.

To add briefly to the context of today’s debate, I looked at the King’s Fund report of 2013, Volunteering in Health and Care. Securing a Sustainable Future, which states:

“The health and social care system is under extreme pressure to improve the quality and efficiency of services. To meet the challenges ahead, service providers will need to think differently about how they work and who they work with … One important group in these debates is the millions of people who volunteer in health and social care, in both the voluntary sector and within public services—an estimated 3 million people across England. These people”—

as the noble Baroness said—

“add significant value to the work of paid professionals, and are a critical but often under-appreciated part of the health and social care workforce”.

The King’s Fund research indicates that,

“volunteers play an important role in improving people’s experience of care, building stronger relationships between services and communities, supporting integrated care, improving public health and reducing health inequalities. The support that volunteers provide can be of particular value to those who rely most heavily on services, such as people with multiple long-term conditions or mental health problems”.

It suggests that, to achieve the best scenario, the critical role of volunteers in building a sustainable approach to health and social care must be acknowledged, and the research recognises five key areas, which I hope we can debate at a future time.

I just want to add topically that, as the noble Baroness pointed out, today the Government are responding to NHS England’s five-year forward plan. In the paragraph on encouraging community volunteering, they acknowledge the importance of volunteers, as I have just described, and they put forward examples of how those volunteers might be utilised most effectively. I hope that the Minister will comment on that. I do not want to stray into the response or the Statement that is to follow but I hope that there will be some recognition of the vital role of volunteers in this country.

As the noble Baroness pointed out, an excellent report on the Hospital 2 Home scheme was produced by the RVS a short while ago. It gave some interesting statistics about the scale of the issue, particularly regarding the over-75s. It is estimated that there are now 5.1 million over-75s in this country, up from 4.4 million in 2010, with there being an estimated 7 million by 2035. Forty-six per cent of those over-75s live alone, and 38% of 75 year-olds now return home from hospital—up from 10% in 2004. The RVS’s report was very timely in showing that a much greater number of over-75s go home from hospital and that they need support to ensure that they are not readmitted, as this debate is about. Before they are discharged, they often feel anxious and not ready to go home. That is often because they know that they are going home alone and that they will not get the support that they require to give them confidence, or may not get the immediate services that are required to ensure that they return home in a satisfactory way and are not looking for early readmission. Early readmission can be a consequence of that anxiety. I am not suggesting that no people in this age group will have to return to hospital, but let us see whether there is a mechanism to ensure that the services that are required to wrap around them at the point of discharge are most satisfactory.

From my experience of working in the voluntary sector with people with mental health problems—particularly those who come into contact with the criminal justice system—I have found that there is very poor evaluation of the cost benefits of the work of the voluntary sector. In the RVS report, it is estimated that savings on readmission are around £40 million a year but there is no solid evidence to support that figure. It is a very good estimation of what those savings can be but the Government should look rigorously at better models for considering outcomes and for assessing the real value to society of volunteers. As I said, from my work with the mental health and criminal justice system, I know that there is a paucity of information about the support that mentoring can give, for example, to people with mental health problems who may come back into the community from the criminal justice system. That value of that to society is completely underestimated. I am not comparing it directly with readmission to hospital but there is a great value to society to be had when we are talking about readmission to the criminal justice system as a result of not having that support. I urge the Government to look very carefully at how we can assess more effectively the savings that can be made through effective mentoring and the use of volunteers.

However, we should never presume that volunteers are in some way a cheap option within the development of public services. They have to be valued as part of the team, and we have to ensure that, when services are commissioned using the voluntary sector, the sector has sufficient support and infrastructure to ensure that it can be an effective part of service delivery. I am always concerned that, as we move into the new contracting arrangements within the commissioning of services, the value of volunteers or the voluntary sector is not adequately taken into account as those contracts are developed to ensure that the high quality and local nature of those services are properly recognised and become integrated into the way in which the 3 million volunteers so willingly give their time and expertise.

I again congratulate the noble Baroness on this debate, and the debate will go forward very effectively now because, as we struggle to ensure that we support people whatever their illnesses or age group, the voluntary sector will become an even more important part of our civic life.

Mental Health Services

Lord Bradley Excerpts

Wednesday 26th November 2014 Lords Chamber

[Earl Howe]

My noble friend is absolutely right: there is a high prevalence of mental health issues in those leaving care. The Government are dedicated to supporting NHS England’s work to develop a service specification for the transition from CAMHS that is aimed at CCG-commissioned services. CCGs and local authorities will be able to use the specification to build on the best measurable services to take into account the developmental needs of the young person. A separate specification for transition from CAMHS to adult services is also in development.

[Lord Bradley (Lab)]

My Lords, does the Minister agree with me and the recent Health Select Committee report into child and adolescent mental health services that it is wholly unacceptable that so many children and young people suffering a mental health crisis face detention under Section 136 of the Mental Health Act in police cells rather than an appropriate place of safety? What action are the Government taking to eradicate this practice immediately?

[Earl Howe]

My Lords, it is unacceptable for a child in a mental health crisis to be taken to a police cell. The mental health crisis care concordat, launched in February this year, reinforces the duty on the NHS to make sure that people aged under 18 are treated in an environment that is suitable for their age, according to their needs. It also makes it clear for the first time that adult places of safety should be used for children if necessary so long as their use is safe and appropriate. We have seen a reduction in the use of police cells across the country but there is still further work to do.

Health: Mental Health

Lord Bradley Excerpts

Tuesday 28th October 2014 Lords Chamber

[Earl Howe]

My noble friend makes an extremely important point. NHS England is currently reviewing the never events framework. My honourable friend the Minister of State for Care and Support will shortly be meeting NHS England officials to discuss the possibility of including suicide following in-patient care as a never event and how the new never events framework will support parity of esteem.

[Lord Bradley (Lab)]

My Lords, NHS England made it clear last week that mental illness costs the economy an estimated £100 billion annually, which is roughly the cost of the entire NHS budget. How do the Government justify only 5.5% of the UK’s health research budget being allocated to mental health and, according to MIND today, a paltry 1.4% of Public Health England’s budget being spent on mental health? Is this what the Government mean by parity of esteem?

[Earl Howe]

My Lords, investment in mental health research by the National Institute for Health Research has nearly doubled over the past four years from £40 million in 2009-10 to £72 million in 2013-14. I hope that the noble Lord will take from that that we put a priority on this. Of course, it is very important that local authorities do not downplay the significance of mental health. We have made it very clear that disinvestment is not an option for them. We are discussing with local authorities this very issue.

NHS: Five Year Forward View

Lord Bradley Excerpts

Thursday 23rd October 2014 Lords Chamber

[Lord Bradley (Lab)]

My Lords, noting my health interests, I am grateful to the Minister for repeating the Statement. We warmly welcome the report, Five Year Forward View, particularly as it endorses key elements of Labour’s plans for the National Health Service. However, there are many questions still to be answered, which will unfold over the coming weeks and months and will form the basis of that measured and intelligent debate in this House. The report endorses Labour’s visions for new models of integrated care, including hospitals evolving into integrated and accountable care organisations, with more salaried GPs. Does the Minister accept these proposals, and does he agree that there should be a greater role for health and well-being boards in helping to deliver this strategy? On public health, does the Minister agree with the report that the time has come for radical action on obesity, and does he accept that the voluntary responsibility deal is clearly inadequate? On GP services, does he agree with the report that primary care has been under-resourced and that people are struggling to get appointments? Will he accept the need to stabilise funding of GP budgets and match our plans to recruit 8,000 more GPs? Finally, does he accept that much more urgent action is needed to deliver the commitment on parity of esteem between mental and physical health and that proper integration of those services is particularly important and will ensure better outcomes for all patients?

Mental Health: Beds

Lord Bradley Excerpts

Tuesday 29th July 2014 Lords Chamber

Asked by

[Lord Bradley]

To ask Her Majesty’s Government what action they are taking to stop patients being unnecessarily sectioned because of shortages of mental health beds.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, we are not aware of any incidents of patients being unnecessarily sectioned. In June 2013, the Care Quality Commission asked for notification of such cases. It is for local clinical commissioning groups to commission the right number of in-patient beds to meet the mental health needs of their local population.

[Lord Bradley (Lab)]

I am grateful to the Minister for that reply, although I am slightly surprised. Does the Minister agree that it is wholly unacceptable that, according to the Royal College of Psychiatrists, doctors are still being forced to section patients to get them their in-patient care? That follows a warning by the Health Select Committee last July on the need to investigate urgently whether patients are being sectioned for them to access psychiatric units, and report to Parliament on the prevalence of that practice. What action have the Government taken on that committee report? Will the Government, if they look carefully at those findings, consider making emergency funding available, similar to that which they made available to A&E departments in the winter, to immediately ease the mental health crisis in beds for adults and children?

[Earl Howe]

My Lords, I am certainly aware that a number of concerns have been raised about the lack of mental health beds and that there are occasions when patients do not receive care quickly enough because approved mental health professionals cannot locate an appropriate bed. As I said in my original Answer, that is essentially a failing of local clinical commissioning. However, AMHPs—approved mental health professionals—should not be put in that position. We are consulting at the moment on a revised code of practice for the Mental Health Act. That consultation includes a specific question which asks what additional guidance should be included to ensure that AMHPs are not put in that position.

Health: Dementia

Lord Bradley Excerpts

Monday 14th July 2014 Lords Chamber

[Earl Howe]

It is generally recognised—although some GPs disagree—that early diagnosis of dementia is vital. It is vital for ensuring that a person with dementia can access the relevant advice, information and care and support that can help them live well with the condition. My noble friend is right that there is currently no cure for dementia, but there are drugs that can help with some of the symptoms and people with dementia have the right to know that they have the condition so that they can better plan for the future.

[Lord Bradley (Lab)]

My Lords, I declare my health interests. The Alzheimer’s Society says that one person in five who suffer from dementia gets no support or information after diagnosis. Will the Minister say what specific actions the Government are taking now to try to improve the situation?

[Earl Howe]

My Lords, NHS England is investing £90 million in diagnosing two-thirds of people with dementia by March next year. We have amended the GP contract so that everyone over 75 has a named, accountable GP and the most vulnerable 2% in each practice will receive an enhanced service. The NHS Choices website has been enhanced. NHS England has provided CCGs with tools and guidance to help them set a local ambition to improve dementia diagnosis. The post-diagnostic support that the noble Lord mentions is absolutely central. There is a post-diagnosis working group to identify what good looks like in this area and roll out best practice.