Mental Health In-patient Services: Improving Safety

Lord Markham Excerpts

Monday 3rd July 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, I am grateful to have an opportunity to discuss mental health provision, and my comments will very much follow on from those of the noble Baroness, Lady Merron. We are also interested in the Government’s latest thinking about the draft mental health Bill. Now that the workforce plan is out—we will discuss it tomorrow—our new refrain may be, “When will the Government get on with the mental health Bill?”. It is long overdue, and a huge amount of work has gone in that is clearly fundamental to trying to deal with some of the structural issues.

Turning to some of the issues raised in the Statement, I first want to ask about people’s journeys when they are in need of mental health support. The Statement said that 111 will now provide mental health advice, which is very welcome, but can I ask the Minister for his thoughts on what is happening in primary care? My understanding is that at the moment mental health nursing provision is not a requirement of all general practices—some offer it and others do not. Can the Minister, who I know cares about joined-up, seamless services, give us some insights into the Government’s thinking on ensuring that people who present with mental health problems to general practice—which is the first port of call for many of them, before they even get to 111 or 999—see more consistency of support available at that level?

Thinking about the review—a major part of what is in the Statement—a significant proportion of providers of mental health in-patient services are private sector, which has been the case for some time. Can the Minister confirm that they will be included in the review and comment on whether the inspectorate’s powers will be applied equally to the private and public sectors? That is critical to understanding what is happening in all settings.

Will the Minister also talk a little about the input the review may get from related services? Again, we know that the police, local authorities and accident and emergency departments often pick up the pieces where mental health provision has not been made available. Can the Minister assure us that the review will also look at all those other parties to this journey of care that people require? Can he also comment on the data questions? I have seen evidence from freedom of information requests to the Office for National Statistics asking about deaths of people in mental health in-patient settings. My understanding is that the data is not recorded consistently. If we are to have a review and to understand what is happening in the mental health sector, it would be helpful to know what measures the Government will take to improve the consistency of data collection so that, when someone unfortunately suffers a tragic incident, we know where they were at the time and have the data available to build up the national pattern.

The final issue I want to ask for the Minister’s comments on is out-of-area placements. Will he acknowledge that it remains a serious issue that many people with serious mental health conditions are able to get treatment only in places that are far from home and therefore far from their families and support networks? I note from the Statement that the Government are providing three new hospitals. This is of course welcome, but I hope the Minister will also be able to confirm that there is a locality-based strategy, with the Government thinking hard about matching local facilities to local need so that we can end the situation in which people at a time of extreme distress are sent very far away from home, which can only add to the crisis they are facing.

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

I thank noble Lords for their questions and their general welcome for the Statement. On timing, we had hoped that doing it on a non-statutory basis would have been sufficient. The advantage is that you get the results that much quicker; you can often get them within a year, versus three years. We have many examples of where it has worked quite well, such as the Kirkup report. To answer the question of why it is taking so long, in the first place we had hoped that doing it on a statutory basis would not have been necessary. There was a course correction in January, when we were not getting the response we needed and not enough staff were making themselves accessible. There was some improvement at that point, but it was felt by the chair that it was not sufficient, hence the decision now.

We believe that we can build on the work that has been done so far, so we are not starting again from zero. However, there are some lessons. On a number of occasions, trusts and staff have responded well to a non-statutory inquiry, but we have learned from this that sometimes it needs to have the teeth of a statutory inquiry so that it is taken seriously enough. Somehow, there was an impression that, because the inquiry was not statutory, it was not seen as serious enough to trigger that. There is a key lesson to learn from all of that.

How we can seek to restore confidence is absolutely the right question to be asking. We believe that the additional investment of £2.3 billion that we are putting into this space is a key part of that, and the increase of 27,000 staff is another. We are learning from the reviews that we are doing, and we are quickly learning from the rapid review. We are working fast, so I cannot give an exact date for those results. We asked for it to be a rapid review so that we could get on with it and make the most of the findings.

The other key part of this is the Healthcare Safety Investigation Branch. We are asking it to look into a number of questions, one of those being out-of-area in-patients and the impact that has. I think we all agree that it is best if people can have in-patient services locally. That is one of the key parts that it will be asked to review. On the timing of that review, it will start in October and should be able to conclude within a year. We should get results back quite quickly.

On the timing of the mental health Bill, we are working through the parliamentary calendar now. We do not know the timings yet, but the scheduling is being looked at.

The noble Baroness mentioned the prevention agenda. I completely agree that care in the community and the training of staff in GP settings and schools are vital to this. As noble Lords have heard me say at the Dispatch Box before, we are making good progress: about 35% of schools are trained up in mental health support. Last year it was only 24% and next year we think we will be pushing 50%. Those are big increases, but I freely accept that 50% is not 100%. A lot of progress is being made in that area but we accept that a lot more needs to be done.

As for the private sector being included in the review, I have every reason to think that it should be and that there should be equal powers, but I will check that. I am talking off the top of my head now as it seems perfectly sensible, but I will come back properly on that.

I will do likewise with the comments on the recording of and use of data. Again, one of the rapid review findings was that we do not have enough real-time data. That is very much the direction of travel but, again, I will come back with more detail. As ever, noble Lords will know that I like to bring all these things together in a lengthy letter where I hope I am able to cover any points I did not cover here.

There are steps in the right direction, and the investment I talked about is another step in the right direction. I completely agree with the emphasis that it is vital we restore confidence in this area.

--- Later in debate ---

[Baroness Buscombe (Con)]

A question is coming. I was accompanied by a brilliant consultant, Julia Riley. She has not even had a cursory note of thanks from those civil servants. Could the Minister therefore please respond by giving a little more detail on the timing? Could he also let me know whether there has been any progress on developing that particular app? I would also like to know about the implementation of safe places, where people can go when they are in crisis.

[Lord Markham (Con)]

I thank my noble friend for her tireless work in this space. We believe that a number of constructive points were made in the committee report, which I know Maria Caulfield is working on and looking to get a timely response to. Maybe that is something on which we can meet up and discuss later.

[Baroness Uddin (Non-Afl)]

My Lords, I raise the issue of the mental well-being of men from black and Asian backgrounds. I particularly raise the issue of the care they are receiving at the hands of very poorly qualified, untrained, unsympathetic people, who do not adequately understand the complexity not just of mental health and well-being but the way that they should be operating. They are not working in tandem with the families, which is one of the requirements. There have been suggestions from a number of community organisations that black and Asian men are four times more likely to be detained, and sometimes it is more than likely that there has not been any consultation with their families, which is one of the prerequisites. Can the Minister assure this House that any formal forward-thinking and examination of these issues is looking at the disproportionality of the effects and the causes of very poor services, particularly for men from black and Asian minority backgrounds?

[Lord Markham (Con)]

Yes, we are very aware of the points made very well by the noble Baroness, including some of the stats on the community treatment orders and the fact, I believe, that if you are a black male, you are eight times more likely to be detained. I know that that led to some of the recommendations from the pre-legislative scrutiny committee. I can give an undertaking that that will be fundamental to what we are trying to do here.

[Baroness Watkins of Tavistock (CB)]

My Lords, I welcome the Statement, but I will raise two issues. First, it seems that several different bodies will look at what the problem is, yet the ombudsman has just said that it is absolutely imperative that

“The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like”.


Could the Minister comment on how that will be considered in tandem with the proposals outlined in the Statement?

Secondly, will the proposals look at a safe staffing model for all in-patient mental health services? In fact, in-patient services are really looking after only those people who have severe mental health problems; they are almost the equivalent of an intensive care unit in a general hospital. Increasingly, staff do not have time for proper continuity of handover when they leave shifts, and that needs to be examined. It is relatively easy to describe somebody’s blood pressure and blood stats in an intensive care unit as you hand over in a general area, but to describe the complexities you have been working with, for example with somebody who has severe schizophrenia and is deluded and paranoid, takes a good 10 minutes in a handover. I would welcome the Minister’s comments on how we will look at ensuring that that is considered when measuring safe staffing.

[Lord Markham (Con)]

I thank the noble Baroness. The points she rightly makes are exactly what we believe is the remit of the new HSSIB review starting from October. One of the specific points is about developing safe therapeutic staffing models for all mental health in-patient services. I think and hope that the exact points raised by the noble Baroness will be addressed by the review.

[Lord Bradley (Lab)]

My Lords, the Government’s draft mental health Bill proposes—and I and the Joint Committee support this—the banning of prisons as a place of safety and the transfer of patients within 28 days of the mental health assessment to a safe mental health secure unit. Will the Minister ensure that this is included in the national review, so that there are sufficient local safe secure facilities to implement the 28-day recommendation and that these patients are cared for in genuine places of safety?

[Lord Markham (Con)]

I understand the concern brought, quite rightly, by the noble Lord. It would be best for me to write on that, so that I can give the specific position and he can have the detail he requires.

[Baroness Berridge (Con)]

My Lords, I am a member of the Joint Committee. We heard compelling evidence from the Independent Advisory Panel on Deaths in Custody that, although there is always an inquest into an unexplained death, there is the unique situation where if you die detained, in effect, by the state but in a secure mental health institution—as opposed to a prison, police cell or immigration detention centre—there is no independent investigative body to investigate the circumstances around your death. Given that this independent inquiry will look at a series of deaths over 20 years, will it be within its remit to look at whether or not, had there been some kind of independent investigation of those deaths, the themes and problems faced by the trust might have been spotted earlier?

[Lord Markham (Con)]

We see that as being very much in the remit of the Health Services Safety Investigations Body. In fact, the first thing we are asking it to do is to consider how we can learn from those unfortunate deaths, where they have taken place, in terms of their care. The intention is that it will report back. It will start in October and will report back on that within a year, so that we can get some rapid findings.

[Lord Hunt of Kings Heath (Lab)]

My Lords, can the Minister return to the contribution from the noble Baroness, Lady Watkins? I note that the HSSIB has been asked to look at and develop a safe staffing model for in-patient services, but I re-emphasise the point made by the noble Baroness: you cannot look at in-patient services only; you have to look at the whole spectrum. Surely, he accepts that. For instance, with young people, the huge waiting times for CAMHS services, which eventually lead to some of them being out-of-area placements, is shocking. Surely, HSSIB should be looking at the whole picture. Can he also say how this will relate to the workforce plan? In other words, will the conclusions of HSSIB’s report go forward into the workforce plan, so that for the future we are developing enough people in the mental health field?

[Lord Markham (Con)]

As I am sure the noble Lord is aware, the second thing that the HSSIB is being asked to look at is exactly the point about how people are cared for as in-patients and how we can improve that approach. On staffing—again, we will debate this more tomorrow night following the Statement repeat—it is vital that there is a feedback loop in terms of the long-term workforce plan. That feedback loop, as I am sure noble Lords are aware, is built into it, so that when new data comes along, as will potentially be the case with the HSSIB, there is a way for that to feed back in again.

[Lord Harris of Haringey (Lab)]

My Lords, I will follow on from the point made by the noble Baroness, Lady Berridge. Until 2015, I chaired the Independent Advisory Panel on Deaths in Custody, which covered the more high-profile areas of deaths in police and prison custody. However, the largest number of deaths under the care of the state was in mental health institutions. The noble Baroness, Lady Berridge, asked about independent investigations and the Minister said that the review will look at what lessons can be drawn. The point is, however, that over the last 20 to 30 years, there have not been independent investigations into the individual deaths, so how will there be an evidence base to decide whether proper lessons were drawn at the time and whether those were acted on?

Secondly, my noble friend Lord Hunt of Kings Heath talked about the difficulties with CAMHS. There is a gulf at age 18 between people being treated under CAMHS and then going into adult mental health services. What are the Government doing to bridge that gap? People who may have received some support from CAMHS then lose it when they go into the adult sector.

Finally—I know I should not ask three questions, but I want to—one of the striking things about the number of deaths that occurred in mental health institutions is that many arose from physical causes. It was not about people committing suicide or their mental health crisis; it was the fact that in a hospital, a place of medical provision, they were not getting adequate physical healthcare. What are the Government doing about that?

[Lord Markham (Con)]

I thank the noble Lord for his commitment in this area over the years. With regard to the first question about past evidence, clearly the HSSIB will be looking at what evidence exists. As the noble Lord said, some investigations go back 30 years, so there will not always be circumstances where it can pick out that evidence, unfortunately. However, where there is that information, we are trying to make sure that we pull it out and learn from it. That is very much the direction of travel. Clearly, if part of the HSSIB’s findings is that we need to make sure that every death in such circumstances is investigated under a certain pathway, then I am sure that will come into its recommendations. In terms of the other questions, I think it is best that I write to the noble Lord, if I may.

[Baroness Bennett of Manor Castle (GP)]

My Lords, the Statement includes a number of themes which it is expected the new Health Services Safety Investigations Body will consider. Not included in that list, however, is the growing role of private provision in NHS mental health care services. This is something that patient groups and others are expressing considerable concerns about. Take, for example, the Priory, where the Care Quality Commission reported that the number of deaths at its sites rose nearly 50% from 2017 to 2020. One of those was the tragic death of 23 year-old Matthew Caseby. An inquest jury concluded that his death was contributed to by neglect, and the coroner issued a prevention of future death report because of continuing risks.

The Priory Group earns more than £400 million from the NHS, and much more from social services. It is now owned by a Dutch private equity firm after it was sold by its former owner at a loss and is financed by a sale and leaseback deal of 35 properties with rents subjected to annual inflation-based escalators. Through the mechanisms in this Statement or others, are the Government going to consider the risks presented by private ownership—particularly private equity ownership—of mental health care services?

[Lord Markham (Con)]

As noble Lords are aware from some of my previous answers, I think the key thing is the quality of output rather than the ownership of an institution. Around the House, we have very good examples of where we believe the Government need the help of the independent sector to increase supply and capacity. That always needs to be done with the right quality of regulatory regime, and that is what we have put in place. From my point of view, I am always going to be looking at the quality of the output and not the ownership of a company.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, on the Minister’s last observation, I think there are a number of noble Lords here who would say that the quality of the output has not been that great from some private providers. It is just an observation.

However, the question I want to ask will take us back to the original observations by the noble Baroness, Lady Buscombe—I was also a member of the Joint Committee. The Minister gave a very brief reply to her questions about what has happened to the many recommendations, the vast amount of evidence and a great deal of hard work that went into producing that report. He even mentioned that it was going to be responded to in a “timely” manner. I think the moment for that has passed. Will the Minister have another go at explaining what has happened to the report and when there will be a response to it?

[Lord Markham (Con)]

I am afraid I do not have the timing of a response on that. Minister Caulfield is very engaged in this area. A number of things have been mentioned. I mentioned the community treatment orders, where we are very mindful of the point made earlier by the noble Baroness, Lady Uddin, about black males being eight times more likely to be given one, and the recommendation that they should be abolished altogether. Those recommendations are very much in our thinking and our knowledge base. I know that Maria Caulfield is working on them, but I am afraid I cannot give the noble Baroness an exact time yet.