Mental Health Bill [HL]

Lord Kamall Excerpts

Committee stage
Monday 20th January 2025 Lords Chamber

[Baroness Parminter (LD)]

My Lords, I want to say a few things about a couple of the amendments. I thank noble Lords for listening and for recognising the situation. It was powerful to hear that, and I am sure that many in the eating disorder community will be delighted to hear it.

I will not repeat what I said at Second Reading, as there seems no need, but in mentioning that, I want to support the amendment tabled by the noble Baroness, Lady Browning, which picks out the focus on community care and the need for more psychiatrists. I and others have made the case for why CTOs can be valuable for people with eating disorders—and for forensic patients, I understand. The value of the CTO is that the individual is helped to engage in the community with their mental health team. It is a multidisciplinary team, but the anchor is the psychiatrist. The noble Baroness was not sure if this was the right place to put her amendment because it has wider ramifications, but it certainly has value in this debate. CTOs, which I believe should be retained, can work only if there are proper multi-disciplinary teams anchored by a psychiatrist in the community, so that those individuals can be kept out of detained settings and engaged in the community. I thank her for bringing that forward, and I support it.

With regard to Amendment 44, I do not support a maximum duration for a community treatment order, because this is about the individual and what they decide, with their multidisciplinary team. What I like about the amendment tabled by the noble Lord, Lord Scriven, is that it rightly says that we have to review community treatment orders. People’s mental health situations change, and it is important to have step points at which people know they will be reviewed. I do not support a maximum time limit but the break points, which his probing amendment talks about, are worthy of further debate and discussion. I am grateful to him for bringing that forward.

I say with regret that I do not agree so much with the support of the noble Baroness, Lady Bennett, for retaining the automatic referral to a tribunal of any CTO that is lifted. Again, that goes against my sense that CTOs are about what is right for the individual. With eating disorders, there will be cases of CTOs being lifted because the person is no longer able to engage with the community team because the eating order has gone beyond the bounds of the CTO and is compromising their health and putting them, bluntly, at risk of death. I do not see why, in those circumstances, there needs to be an automatic referral to a tribunal. Strengthening people’s rights to go to a tribunal where there is a case for that is right and proper, but, because of my view about personalised care—especially for eating disorders, but this has wider ramifications—I do not support the case for automatic referral.

I know that there are people around the Committee who understand the concerns far better than me, particularly about the high preponderance of people in the black community who are on CTOs. I understand and hear that concern. I tried to get to the bottom of the figures, like the noble Baroness, Lady Bennett, to find out how many forensic patients were on CTOs. Given that you are four times more likely to be in prison if you are a black person than a white person, I tried to work out what the figures were to get the correlation to say whether it is because there are more people in prison that CTOs are preponderantly in the black community. I could not work that out. Equally, I could not work out how many people with eating disorders were on CTOs. I got the Library to try to help me, and it said that the figures are not cut that way and do not work that way. It seems to me that there is an issue about the data that we, and the Minister, are working with to make informed decisions.

I am not sure about the exact terms and conditions of the review that has been proposed by the noble Lord, Lord Kamall, and which in a later group is proposed by the noble Baroness, Lady Tyler, but I think there is an issue about the data out there. It is not helping us, or anyone else, make CTOs work for those where they can work, are working and should work in the future, and is clearly causing a problem. We need to get to the bottom of that.

[Lord Kamall (Con)]

My Lords, I thank all noble Lords who have spoken on this group. I will speak to Amendment 66 in my name and that of my noble friend Lord Howe. One of the motivations when we were considering amendments from our Benches was not only to respond to concerns raised by stakeholders but to probe the Government on why they did not accept some of the recommendations of the pre-legislative Joint Committee. That is the nature of these amendments. To the noble Baroness, Lady Fox, I say that the amendment is meant as a probing amendment to ask the Government why they have not adopted all the recommendations of the Joint Committee.

One of the things that drives many of us—I feel particularly strongly about this, given my background—is why so many people of an Afro-Caribbean background are being detained or are subject to CTOs. The noble Baroness, Lady Parminter, made a valuable point. One of the reasons I have tabled other amendments along those lines, which will be discussed in later groups, is that, after all these years of saying that too many people from the black community are being detained, if we want to do something about it, we need data, and we need to understand why they are being detained. Without the data, it is left to rumour or speculation, or people make up reasons. Everything needs to be driven by the data if we are to address the fact that a disproportionate number of black people are detained.

We tabled Amendment 66 because the pre-legislative committee recommended that community treatment orders be abolished for Part II patients, those not in the criminal justice system, and wanted a statutory process and timeline to be put in place for the review and potential abolition—I say those words from the Joint Committee’s recommendation very carefully—for Part III patients, those involved with the criminal justice system.

Many noble Lords came to the Second Reading debate wanting to see an end to community treatment orders, and many noble Lords have spoken tonight about this. We were all struck by the words of the noble Baroness, Lady Parminter, and of the noble Baroness, Lady Barker, who very honestly said that, having listened to patients and families, she knows that there is a small group of people for whom CTOs work, are the least restrictive option and are beneficial, and we should therefore keep them. I was particularly struck by that. The noble Baroness, Lady Fox, said that people do not change their mind very often, but the views that we brought to the debate in the first place have been challenged.

The noble Baroness, Lady Barker, made the important point that, while she is reluctant to admit it, she believes that there should be a change in the process around CTOs. That is important. This is why this probing amendment is asking for a comprehensive review of CTOs. We have listed a number of criteria that should be in that review, but I know that many noble Lords have concerns over CTOs.

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[Baroness Merron (Lab)]

I can understand the frustration that the noble Baroness outlines. It is hard for me to comment on a number of those 20 years. My feeling is that that is why we are here today updating the Bill. Indeed, at the risk of repeating myself—I will try not to—I take the point that she is making, yet I feel there is a need, under the updated Bill, which I hope will become an Act, to review the overall impact of the new provisions. I understand that we cannot be on a hope and a wing and a prayer. That is not the intention. We will keep CTOs under review as we implement changes. I certainly want to keep a very close eye on their impact, as I know your Lordships’ House will. I know that noble Lords will not be shy to raise any concerns that they have.

Amendment 66, in the name of the noble Lord, Lord Kamall, and supported by the noble Earl, Lord Howe, would require the use of community treatment orders to be reviewed within two years of the Act being passed. As a number of noble Lords have said, we believe that CTOs can be valuable for certain patients—indeed, as we have referred to, the noble Baroness, Lady Parminter, spoke about their benefit for eating disorder patients, as she did at Second Reading—but reform is needed so that they are used only when appropriate and for the shortest possible time.

The noble Lord, Lord Kamall, made a couple of points, which I am happy to write to him about, about concerns about resources. He asked about the role of mental health nurses—an important point—and the effectiveness of CTOs. I will write further on those points.

[Lord Kamall (Con)]

If the Minister and the officials look at Amendment 66, they will see it asks four specific questions. It could include more, but I wonder whether we can understand what the Government understand about each of those four things, including the impact of community treatment orders on people from different ethnic minorities and the effectiveness of the continued use of community treatment orders. I think it would be interesting for noble Lords to understand what the Government currently understand, if that makes sense.

[Baroness Merron (Lab)]

Yes, it does. I thank the noble Lord for the clarification. I will come to some of those points, particularly on racial disparity, but I just wanted to ensure that I did not miss the points that he made.

The noble Baroness, Lady Parminter, raised how people with eating disorders will be supported on CTOs. To elaborate a bit on what I said previously, for some people CTOs allow them to be cared for in the community with the least restriction, but with the safeguard that they can be recalled for treatment if necessary. That is a very necessary aspect.

I hope noble Lords are aware that I certainly would agree about the importance of the right data being used to inform decisions, trends and reviews. Data on community treatment orders are published as part of the annual Mental Health Act statistics. My officials are working with NHS England and others to understand what additional data should be collected to understand the impact of the reforms—this relates to the points made by the noble Lord, Lord Kamall.

I know that noble Lords more than understand that gathering new data takes time. Therefore, it is felt that a review after two years would be somewhat premature, as it would be based on data from before the reforms were commenced. So, rather than committing to a review in legislation at a fixed date, the Government are committed to ongoing monitoring of CTOs as we implement the changes. This will form part of our overall commitment to evaluate the impact of reform and to consider next steps. I am sure that your Lordships’ House would wish to continue to be involved in this.

I turn to Amendment 67, tabled by the noble Baroness, Lady Bennett, requiring a review of economic and social disparities in relation to CTOs. I agree, as I have many times, that there are significant disparities in the use of community treatment orders, particularly between different minority ethnic groups. This was spoken to by not just the noble Baroness, Lady Bennett, but the noble Baroness, Lady Berridge, and the noble Lord, Lord Scriven. I will make a few points about this. Those who are black are currently seven times more likely to be detained on a CTO—we have discussed this in your Lordships’ House a number of times, and rightly so, in my view. For CTOs, we are strengthening decision-making in three ways: first, by requiring that an individual must be at risk of serious harm to be made subject to a CTO; secondly, by requiring that the community clinician be involved in all community treatment order decisions; and, thirdly, by increasing the frequency of automatic reviews of patient cases by the tribunal. We will work closely to ensure that the Bill’s provisions are effectively implemented, because a main plank of this legislation is to reduce racial disparities in decision-making under the Act. I am sure we will return to this point many times, and rightly so.

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[Baroness Berridge (Con)]

My Lords, I will speak briefly to support the amendment tabled by the noble Baroness, Lady Tyler. The extension of advocacy services to children and young people is important, because, as she outlined, there is a disproportionate number of children who are voluntary—I think there are just under 1,000 a year—in mental health institutions.

It is also important to recognise that there are other additional rights that children have when they are detained, or when they have agreed and consented to go into hospital. They need to continue their education while they are in there. It is important to advocate for what their entitlement is while they are in hospital—I think we are all used to walking past the hospital school that is within a normal physical illness hospital—thereby enabling them to continue their education and considering what their rights are in that regard. That is obviously so important for them and their recovery, so I support the amendment from the noble Baroness, Lady Tyler.

[Lord Kamall (Con)]

My Lords, I have a few brief comments on this group of amendments. In response to Amendment 43A, tabled by the noble Baroness, Lady Barker, given that anyone subject to a CTO already receives something in writing, it should not be too difficult for the Government to accept her amendment. Assuming that they have a right to access independent mental health advocates, it seems like a very reasonable amendment.

Like the noble Baroness, Lady Tyler, I must admit that, when I read the amendments tabled by the noble Baroness, Lady Murphy, I wondered—given that the amendments from the noble Baroness, Lady Tyler, and the noble Lord, Lord Scriven, seek to extend access to independent mental health advocates—why she would want to exclude informal patients from access to those advocates. However, as she explained, and as my noble friend Lady Berridge commented on day one in Committee, we have to deal with the world as it is, not the ideal world that does not exist. As the Minister has often reminded us, this will not all happen in one big bang; the Government’s plan is for it to take over 10 years, subject to spending reviews and resources.

In fact, the noble Baroness, Lady Murphy, made what appear to be two valid points. The first is that we need to be realistic about resourcing. As the impact assessment suggests that expanding access to independent mental health advocates to informal patients will cost £81 million every year, we have to ask: is that the best use of that money, if it were available, given all the other demands on it?

On the noble Baroness’s second observation, I thought that the research cited was interesting: that extending these independent mental health advocates from one environment or cohort of patients to another does not necessarily mean that it will work.

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[Lord Scriven (LD)]

I am reading the impact assessment, and the annual amount is between £6 million to £7 million, and not £81 million. Perhaps the Minister could clarify that when she responds, as the impact assessment that I am reading is different from the £81 million that the noble Baroness, Lady Murphy, and the noble Lord, Lord Kamall, are referring to.

[Lord Kamall (Con)]

I thank the noble Lord, Lord Scriven, for that, as I would not want to be using inaccurate information. Maybe the Minister can check with her officials, thanks to the wonderful use of technology, to ensure that we have an accurate figure by the time that she gets up to respond to our points. Whichever number is accurate for the cost of extension, it does have an impact on how noble Lords may feel if these amendments come back on Report.

The study that the noble Baroness, Lady Murphy, shared with us contained two statements which I picked up on, and which I hope the noble Baroness will correct if I am wrong. First, patients found the process was a positive experience. But, secondly, the study found no evidence that it had any impact on the outcomes of the care and treatment. That is an important point to make. Once again, what is effective, and what works? Sometimes, feeling better and being more positive is part of a treatment, and we should not dismiss that.

I do not want to sound too negative, as I thought that the North Carolina study was very positive, and the noble Baroness and I corresponded about this over the weekend. It was interesting that it found that black mental health patients benefited from having an independent mental health advocate, especially if the advocate was also black, as patients felt better supported, and more confident that they would be listened to by someone. The crucial point was that it appeared to reduce the rate of repeat detentions. This is one of the crucial issues throughout the Bill. This is one of the reasons why my noble friend Lady May asked for the Wessely review.

[Baroness Berridge (Con)]

I do not wish to interrupt my noble friend’s flow, but this is one of the key things that is evidence-based, and that does reduce detention for those communities, so it is important.

[Lord Kamall (Con)]

I am grateful to my noble friend for that intervention, because this is something that we could learn from here. Given the point that the noble Baroness, Lady Murphy, made at the beginning, would taking that lesson from the black community in North Carolina work with black communities up and down the country here? I hope it is something that the Government could look into, or respond to, as one of the ways, once we have the relevant data, to reduce the rate of detention and CTOs for people from the black community.

I end by asking the Minister that question: is she aware of whether her department has looked at—was it North Carolina or South Carolina?

[Baroness Murphy (CB)]

North Carolina.

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[Lord Kamall (Con)]

I would not want to upset any people from South Carolina. In fact, I did some work in Raleigh and Durham a few years, so I should get this right. Is the department aware of that study, and has there been any analysis of what could be learned from that study which could be relevant to the United Kingdom, especially given one of the main reasons we are here tonight is to reduce the disproportionate detention of people from black communities? I look forward to the Minister’s responses.

[Baroness Merron (Lab)]

My Lords, I thank all noble Lords who have spoken to and tabled amendments for this important discussion, which, I am sure my Whip will tell me, will be the last one of the evening.