That this House has considered reform of the Mental Health Act 1983.
It is an absolute pleasure to serve under you in the Chair, Ms Buck. I thank everyone who has come along to speak on our last day here before the summer recess and in 38° heat—we are used to 38 Degrees in our inboxes, but not in the Chamber. I also thank all the organisations that have supported this debate. In particular, I owe deep thanks to Louise and the whole team at Rethink Mental Illness for supporting me in preparing for the debate, but a huge range of organisations work on this issue day in, day out, in many cases supporting people in very difficult circumstances. They include Agenda, the Mental Health Network, the Royal College of Psychiatrists, Young Minds, SANE, the Mental Health Foundation, VoiceAbility, the Centre for Mental Health, the Association of Mental Health Providers, Mind, and Southwark Carers, which is represented here today. I thank you for everything that you do, on a daily basis, to support reform of the Mental Health Act 1983 overall and for what you have done to support this debate specifically. I also thank the individuals with direct experience and their families, friends, carers, supporters and loved ones. Their personal testimony and experience are what is driving the need for change.
The current Mental Health Act came into force in September 1983. Margaret Thatcher was still Prime Minister—what she would make of the current one I do not know, but that is a different issue. Labour had lost the general election that year with the “longest suicide note” in British political history—but luckily we have learned the lessons of the past. The iron curtain was still drawn. It was the year that Kim Jong-un was born. It was the year that my predecessor in Bermondsey and Old Southwark, Sir Simon Hughes, was getting started on a 32-year stay, until I won the seat back for my party in 2015. I note that the biggest selling single in 1983 in the UK was Culture Club’s “Karma Chameleon”.
For anyone unfamiliar with it, the Mental Health Act is the law in England and Wales that allows someone to be detained and treated for a mental illness without their consent. That is commonly known as sectioning, but for the purposes of today’s debate, I will refer to it as detention. The Act is designed to prevent people experiencing mental health crises from harming themselves or other people, and the Act can be the mechanism that prevents someone from taking their own life. It is hugely valuable when it works. I am sure that everyone here would agree that society and the state should protect the most vulnerable when they are unwell. But the current legislation is decades out of date.
The legislation came into force when I was just four years old, and I had already realised by that point that my life was very different from that of other children. My parents had four children together between 1976 and 1980, but mum then developed schizophrenia—a mental illness that causes muddled thinking or delusional thoughts, and changes in behaviour. The causes of schizophrenia are still very much unknown, but even less was known about the condition in the early ’80s and treatment was rudimentary to say the least. But because of mum’s condition, talking about mental illness has been part of my life for as long as I can remember. That has been the case throughout my family because of our circumstances. It has shaped my life.
Some of my earliest memories are not necessarily the easiest to talk about, but this is one of the earliest memories I have. After mum’s mental health broke down, my parents split up. We stayed with mum initially. She was unable to care for us properly. With the best of intentions, on a cold day when she could not work the heating, she lit a fire in our living room. That fire caused huge damage. The scars from the fire stayed with us literally—physically—because we could not afford to make the necessary changes for some time after that.
Mum kept me out of school, convinced that I was ill; there was no illness. For many years, I was convinced that I had been kept in an incubator after being born, because mum convinced me that I had had lung problems at birth. I found out later that that was not true.
Dad eventually got custody, and the four of us grew up with dad, but on visits to mum, she would be unsupported and unwell. I remember staying over and her giving me a bowl of cereal with what I thought was orange juice on it—the milk was so off that it was orange. But mum had thought that that was sensible; she was just trying to feed us. She did not know, because she was so unwell.
Mum had another son; I have a half-brother called Sebastian. She was unable to look after him because she did not have support. He was initially fostered, but mum’s behaviour became too problematic. I went to see her once and the front door had been broken in. She told me that there had been a burglary, but nothing was missing, and it turned out that the police had had to be called because she had taken Sebastian from the foster carers and they had had to break in to take him back. He was formally adopted at five years old, and I have not seen him since.
It may sound strange or scary to some, but this was my normal; this was my childhood. We are all socialised by our surroundings and families, and the personal situation for me and for many others who grew up in difficult circumstances helps to develop resilience, I think. It has also given me greater empathy, both as a child and now, particularly when I see constituents who are struggling with similar mental health circumstances of their own. I represent a constituency that has a higher prevalence of mental health conditions and psychoses.
I commend my hon. Friend not only on the speech that he is making, but on the very moving way, if I may say so, in which he just spoke about his personal experience and how it informs his views today. Like him, I have had constituents who are dealing with these issues; and like him, I think that we have come to the point at which the Mental Health Act does need to be reviewed, particularly because of—this is the point that he has been making—the impact it has on the immediate family. How can we go forward such that the wishes of the person who is being detained are taken into account and the family’s wishes are taken into account, in a way that provides protection for the vulnerable but also recognises people’s particular needs and choices?
That is very much what I will be coming on to and what I hope we will hear more from the Minister on; it was the subject of an independent review.
I was talking about the prevalence of mental health conditions in Southwark and people I have seen at constituency surgeries. These statistics for Southwark are from the South London and Maudsley NHS Foundation Trust, which is my local mental health trust. Close to 4,000 people have what it defines as a serious mental illness; that does not include things such as dementia. Almost 48,000 people are currently experiencing a common mental health condition. Across the borough, 22,000 people have both a mental health condition and a long-term physical condition. And almost 4,000 children in Southwark have a mental health condition.
I thank my hon. Friend for making a speech that is very powerful and very personal. The number of mental health nurses in England has fallen by 6,000 in the past 10 years. Does he agree that we need the correct number of staff, and staff with the correct expertise, to meet the needs of the service in supporting people with mental health issues?
I absolutely agree and will come on to some of those figures.
I referred to the children in Southwark who have mental health conditions. The NHS’s overall target for ensuring that children and adolescents can access mental health treatment is just 35%. That is remarkably low, and I hope the Minister will have something to say about it today. In the meantime, while that is the national standard, Southwark’s Labour council has set an ambition to ensure that 100% of children and adolescents can have access to mental health care. As part of that commitment, the council has made £2 million available for local schools to support the emotional wellbeing and mental health of pupils. It is also developing a mental health hub service for young people. That is in partnership with—jointly funded by—the local clinical commissioning group.
As I have said, I think that my personal experience has given me an additional strength in working with local people and families who are affected by these issues, but being open about my family experience does not mean that I have not seen discrimination or stigma at first hand. I was about 10 or 11 when I said to a friend at school that Mum had schizophrenia and he asked whether that meant I had two mums. That was a surprising reply, but obviously there was a lot of confusion then about what schizophrenia actually was. Some of it is still out there.
Sadly, one thing that remains is the perception that people with schizophrenia are somehow more dangerous. Actually, mum’s experience and that of many people with schizophrenia is that they are more likely to be targeted, because their erratic behaviour when they are unwell can draw the attention of others, who might target them for robbery and other offences.
I thank my hon. Friend for the way in which he is opening the debate and particularly for his comments on schizophrenia. If they have the right support, there is no reason why anyone with schizophrenia should not live a normal life, including being able to work.
I completely agree. Sadly, the figure for people with schizophrenia in work remains at about 5%. It is just 5%, because the support simply is not there and the medication and treatment are not there on a routine basis to ensure that they are able to work.
Figures suggest that one in four of us will experience mental ill health at some point in life, often because of bereavement or a relationship breakdown. I pay tribute to all the organisations involved in the Time To Change campaign, which has done brilliant work to challenge the stigma and discrimination that affect people with mental health conditions in employment and elsewhere.
The change in language and awareness of conditions is one reason to seek reform now. For example, the Mental Health Act 1983 is defined as:
“An Act to consolidate the law relating to mentally disordered persons.”
The language around mental health has changed much since the current law was enacted. We also need to consider its far reaching powers.
The independent review of the Mental Health Act, published seven months ago concluded:
“The Mental Health Act gives the state what are amongst the most significant powers that it has; the power to take away someone’s liberty without the commission of a criminal offence and the power to treat that person even in the face of their refusal. Because of that, we think that is important that the purpose of the powers is clear, as should be the basis on which they should be used.”
It is hard to disagree with that conclusion, especially given the number of people who are affected by those extensive powers.
I congratulate my hon. Friend on securing this debate, and on his personal and emotional contribution—I believe that adds everything. People living with dementia also fall under the Mental Health Act. There are concerns around section 117 and the right for aftercare support once someone is detained under the Mental Health Act, particularly those living with dementia. Does my hon. Friend share my concerns on that?
Certainly, there is insufficient support for a whole range of people. We have sadly seen a roll-back of support, independence of choice and control in a number of areas, including social care support, health services and direct benefits for some disabled people, particularly in the past nine years.
The extensive powers, which I described, were used to detain 50,000 people last year—a 47% increase in the past decade. The only other people detained in this country are those in criminal custody. Those citizens have safeguards to protect them from going to jail, but we do not have the same safe standards of support and safeguards for mental health care. Those who commit a criminal offence have a police investigation, the CPS evidence threshold, a trial, the right of appeal and advocacy throughout, but for the 50,000 detained under the Mental Health Act few such safeguards exist, despite the deprivation of liberty, choice and control.
We can turn this situation around. The independent review of the Mental Health Act, chaired by Professor Sir Simon Wessely, recommended that four principles be written into a revised Act. First, it recommended that choice and autonomy, even for someone detained under the Act, must be respected, enabled and enhanced wherever possible. Secondly, it recommended that the compulsory powers contained within the Act should be exercised in the least restrictive way possible. Thirdly, it recommended that services and treatments should be of therapeutic benefit and delivered with a view to minimising the need for Mental Health Act powers to be used. Fourthly, it recommended that the individual must be respected, and that care and treatment must be provided in a manner that treats them accordingly.
I seek the Minister’s views on those principles being incorporated in forthcoming plans. If those four principles had existed when my mum was detained—she has been sectioned more times in my lifetime than I can remember—I would have had more reassurance that her needs, rights and wishes would have been the starting point for the care and treatment she received. Sadly, that was not the case.
Does my hon. Friend agree that a new mental health Act must prioritise children and young people? The statistics relating to young people are cause for concern.
It certainly should, but we should not have to wait for new legislation—some measures can be taken before that. Given that the White Paper is due by the end of the year, legislation many not come soon enough to help some of those young people who are experiencing problems now.
I hope the Minister will indicate that the Government’s rhetoric on parity of care will be matched by action on preventing the need for detention. Sadly, all the evidence points in the other direction. Parity of care—the requirement to treat mental and physical health equally—was enshrined in law in 2012 and became part of the NHS constitution in 2015. Although mental health accounts for 28% of the overall disease burden, as the NHS terms it, it received just 13% of NHS funding, according to the Centre for Mental Health. In cash terms, the King’s Fund has shown that between 2012 and 2017, funding for acute and specialist hospitals grew by almost 17%, while that for mental health trusts grew by just over 5.5%.
The Royal College of Psychiatrists has found that, taking into account inflation, the real-terms income of mental health trusts across the UK has fallen since 2011. It says that 62% of mental health trusts in England reported a lower income at the end of 2016-17 than in 2011-12. Sadly, only one trust experienced a rise in funding in all five financial years. The Royal College of Psychiatrists has also reported that mental health trusts received £105 million less in 2016-17 than in 2011-12, at today’s prices. There is no parity of funding, even though the Government are legally committed to it.
The 40% rise in detention over the past decade has come at the same time as a loss of overnight beds—between 2010 and 2017, the figure went down from more than 25,000 to less than 20,000—and a 15% decrease in the number of mental health nursing posts. Demand is rising as a result of detentions, but the number of staff has diminished and there is also less space available. The Care Quality Commission, which regulates mental health services, has reported that previously preventable admissions are now not being prevented because of cuts to less restrictive alternatives, such as community mental health services. There has also been an increase in the number of people with at-risk factors when it comes to detention, such as social exclusion and untreated drug or alcohol misuse.
Thank you, Ms Buck, for calling me so early in this debate. I am sure that I speak for everybody who listened to the remarkable speech of the hon. Member for Bermondsey and Old Southwark (Neil Coyle) when I say that it was a privilege to do so. We should all be immensely grateful to him for illustrating the important policy points that he had to make by means of his agonising experiences in his immediate family in his very early years. We all thank him for it.
Given how many hon. Members wish to contribute, I will speak very briefly. I note that the hon. Gentleman’s speech was briefly interrupted by some shouting outside the Chamber to do with Brexit; it seems to be a common theme that mental health debates tend to happen at times when they are overshadowed by other issues. For example, when I became a Member of this House in 1997, I came second in the private Member’s Bill ballot. I chose to introduce the Mental Health (Amendment) Bill, which was designed to achieve improvements for people who suffered catastrophic breakdowns such that they needed to be admitted to acute mental health units.
At that time, the person who came first in the ballot chose to address a subject of massive national importance, namely the banning of hunting with hounds, and I could not help but notice the contrast between the packed main Chamber on the Friday that was considering the welfare of foxes and the rather more thinly occupied main Chamber a week later, as was customary, when we were trying to consider the welfare of human beings. It was ever thus.
The points at issue then are, to some extent, still points at issue now. They have already been touched upon, at least in part, in the excellent opening speech that we have all heard. My particular concern was the need for there to be separate therapeutic environments for people who had to be admitted to acute units who suffered from very different types of mental illness. In other words, the idea that somebody suffering from acute depression should be cheek-by-jowl with somebody suffering regular psychotic outbursts was obviously a recipe to make a very serious situation even worse.
I am delighted to see the hon. Member for Bermondsey and Old Southwark indicating his agreement. It meant that they would not then suffer a much worse breakdown, which would have meant that they would have to be incarcerated, for want of a better word, for a much longer period.
To prevent people, including people living with dementia, from having to be admitted to hospital, there needs to be community support and after-care support once people are discharged, to ensure that they can be kept as healthy and independent as possible in the community for as long as possible.
The hon. Lady is absolutely right, as long as we recognise that what is needed is a range of facilities. Even the most ardent advocate of doing away with in-patient beds would, if pressed, admit that there will always be some people who at some point absolutely need to have some in-patient treatment.
If there are some people who need to go in for a considerable period of time, and hopefully there are a lot more people who do not need to be admitted to acute units at all, it follows almost logically that there will be some people who are on the borderline between the two, who can get by in society with a degree of self-awareness—either their own or that of their immediate family—and that when the warning signs appear, provided there is that network of specialist care with beds for very short-term stays, they can receive what I call a “top-up”, or, if we were talking about servicing a vehicle, something that will prevent a much greater collapse from happening later, with all the consequent horrors.
The question of what happens when people are admitted to acute units arose on a second occasion. I mentioned the first occasion, when I tried to introduce my private Member’s Bill in December 1997 and it was overshadowed by foxhunting. On a second occasion—on 9 December 2010, to be precise—I had secured an Adjournment debate on what happens about the information that is given to someone’s nearest and dearest when an adult is sectioned and goes into an acute unit. That occasion was on the day of the key debate about the trebling of student tuition fees, so once again we found mental health being somewhat upstaged by other matters that were of national importance. However, that is no reason not to persist or not to continue to try and emphasise to Ministers how these issues will never go away until they are finally tackled.
On that occasion in December 2010, I raised the case of the daughter of my constituents, Mr and Mrs Edgell. Sadly, their daughter—who was called Larissa but known as Lara—had taken her own life in 2006. For two years prior to that, the medical authorities had refused to share information about her with her parents; because she was an adult in her thirties, they refused to share vital information about her suicidal thoughts with her parents, on the grounds of patient confidentiality.
As always, it is a pleasure to see you in the Chair, Ms Buck. I congratulate my hon. Friend the Member for Bermondsey and Old Southwark (Neil Coyle) on an incredibly powerful speech that was very detailed and knowledgeable about this issue. Obviously, my hon. Friend was speaking from personal experience, which was very brave of him.
It is clear from the findings of the independent review of the Mental Health Act, published last year, that the current legislation needs significant reform. There has been a 47% increase in detentions under the Act over the past decade, while the proportion of people living with a serious mental illness remains relatively unchanged, so clearly there is some imbalance there; it cannot be right that the number of detentions is going up. I echo the points that have been made about the link between this issue and the cuts to, and failings of, other services in the community that might be able to help at an earlier stage. Perhaps that is one reason why people are ending up in the most serious of circumstances; that is, being detained.
Being detained in a secure mental health unit is obviously going to be an intimidating and frightening experience for anyone. However, it is particularly intimidating for people with learning disabilities and autism, especially young people with those conditions, so I will focus on those groups in my speech. I raised this issue at Health questions on Tuesday, and the Minister—not the hon. Member for Thurrock (Jackie Doyle-Price), but another Minister from the Department of Health and Social Care—gave a very thoughtful response.
One of the things that the Minister said was that learning disabilities, autism or other special needs are often not diagnosed until a child is detained in a mental health unit, which again shows the failings. Child and adolescent mental health services are incredibly under-resourced, and schools are really stretched when it comes to education, health and care plans and working with children who show signs of mental health problems. It is so important that we put proper resources in, so that we can give those children the help they need as early as possible. I am sure that the Minister responding to today’s debate, the hon. Member for Thurrock, agrees with that.
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This is the first debate to be held on the Mental Health Act since that review was published, which is astonishing, given the level of use of the powers in the Act and the level of support for reform. The review made 154 recommendations. The Government accepted two immediately and agreed to publish a White Paper by the end of this year to bring forward full legislation. I welcome that; there is no one who does not want to see that. However, given the paralysis caused by Brexit, and the new Prime Minister and Cabinet, can the Minister confirm that that timetable has not slipped?
Clearly, it is not in someone’s best interest to be detained if that is avoidable. A breakdown of mental health and behaviour can be deeply damaging for individuals, and their families and loved ones, but detention is extremely costly, especially compared with drug and alcohol treatment services or other interventions and support in the community. The average cost of each detention is estimated to be just over £18,000. The 50,000 detentions over the past year cost an estimated £900 million. That money could have gone so much further in earlier interventions to prevent detention.
Of course, there are also costs to how people are identified or present themselves in crises that result in detention. Sometimes they are homeless. I know the Minister has done a lot of work on that. We have met on several occasions and I know that she views homelessness as a public health issue—an issue that overlaps with the topic of this debate. Homelessness as a result of mental ill health increases physical health issues, which result in costs to the NHS.
Sometimes people in crisis are identified by the police. The last time my mum was sectioned—I think it was in 2016—she had had a car accident in which she hit a bollard. No one was injured, but she was prosecuted for the accident. My family and I—including my sister Alex, who I know is watching—had sought help for mum. We knew that she was becoming unwell and that she was not taking her medication, and we tried in advance to alert people to her need for support and to get her back on track, but that did not happen. She had agreed to plead guilty when the case went to court—she was guilty; she hit the bollard and no one else was responsible—but when she was asked how she would plead, she said that she could not be guilty because she had been wearing blue that day. Of course, that made no sense to anyone and resulted in the ordering of a psychiatric assessment, which was a pathway back into mental health care.
That was not necessary. Police and court involvement cause unnecessary cost to the taxpayer. If earlier interventions had occurred at the request of family members, that could have been avoided. I ask those hon. Members who have not been out with their local police and emergency responders to please do so. The last time I did it in Southwark, the police responded to a surprising number of 999 calls that involved someone with a mental health condition. That is not just anecdotal evidence; it is backed up by national statistics.
Troublingly, police statistics show an increased use of section 136 of the Act. That power is used by the police exclusively to remove
“mentally disordered persons without a warrant.”
Between 2015-16 and 2017-18, the use of that power in Southwark doubled, from 60 detentions to 121. That number fell slightly last year, but the shocking overall rise shows the price of underfunded mental health services, with the police often picking up the pieces in situations that should be handled by healthcare specialists and community interventions. Of course there will be some who are unknown to services, but most are not, and there are some who present with issues relating to suicide. Tackling the majority of cases upstream should be the target. I hope the Minister will state how that will be done through a White Paper or new legislation.
I welcome the previous Prime Minister’s commitment to end the use of police cells to detain people who are experiencing mental ill health. I hope that that commitment will continue under the new Government, because a police cell is no place for someone who is experiencing a mental health crisis. Although there has been a 95% fall in the use of cells and custody facilities since 2011, in the latest figures from 2016-17 they still accounted for almost 4% of detentions. I hope that the Minister will set out when the Government expect the number of people going through the system to be zero.
The point that I am trying to ram home is that overreliance on sectioning and detention can be bad for the individual and their families, but also for the taxpayer. We can do better than that. It is not just a matter of the loss of liberty; the Care Quality Commission has also sounded the alarm over risks for people when they are detained, including compulsory treatment and sexual assault. It reports that almost one fifth of patient records—double the proportion in the previous year’s study—
“showed no evidence of consideration of the least restrictive options for care.”
It also stated:
“We have seen limited or no improvement in the key concerns we have raised in previous years.”
That is the regulator saying, “Not only have we identified the problem this year, but we told you about it in previous years, and still no improvement has been made.” Its evidence shows that 1,120 sexual safety reports were made in a three-month period in 2017, of which 457 were about sexual assault or harassment of patients or staff. Some of our most vulnerable citizens are at risk of sexual assault while they are detained under the state’s powers. That is an absolutely appalling record in any civilised society.
These problems all undermine mental health treatment and use of the Act and make it no surprise that research commissioned by the Mental Health Alliance shows that individual experiences of being detained under the Act are far from positive. It surveyed more than 8,000 people, and the majority of respondents who had been detained did not believe that the Mental Health Act sufficiently protected them from inhuman or degrading treatment. Some 61% of respondents who had been detained disagreed with the statement, “People are currently treated with dignity when detained”, as did 41% of mental health professionals. The unity behind the case for reform and true parity of care could not be clearer. I hope that the Minister will cover those issues and confirm more of what the Government aim to put in their Bill when it appears, including human rights provisions.
At the Disability Rights Commission in 2004-05, I helped to bring organisations of and for disabled people together behind the principles that were then put in the Mental Health Act 2005:
“A person must be assumed to have capacity unless it is established that he lacks capacity.
A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success.
A person is not to be treated as unable to make a decision merely because he makes an unwise decision is made.”
Our right to make bad decisions is enshrined in legislation. I apologise to any smokers present, but they make a bad choice every time they light a cigarette, and arguably the Conservative party has chosen badly in selecting the right hon. Member for Uxbridge and South Ruislip (Boris Johnson). The fourth and fifth principles are:
“An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests.
Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action.”
We have precedent in legislation, and we need to support that approach again in reforming the Mental Health Act, with a resolute belief in patient-centred care, with as much choice, control and dignity as is humanly possible.
People’s experiences of being detained vary wildly. It cannot be right that some people are treated worse simply because the place where they become unwell does not have access to the right level of support. We need more standardised access to care, and more standardised care when it has to be provided. I recognise that detention cannot always be avoided, and that it has welcome results when people come out better than when they went in, but even when it is necessary, it must be done better—and there are ways to do that.
Advance decisions were one of the review’s two recommendations that the Government accepted. It is crucial that patients be involved in planning their care as much as possible. The Care Quality Commission’s research shows that under the current legislation, a staggering one in five patients detained have no input whatever in their care plans. It examined the plans in place for those patients and found that most of them were of poor quality, lacked planning and had no evidence of patients’ consent to treatment when they were admitted to hospital. Introducing advance choice documents so that people can set out their wishes about future care and treatment, and giving them more legal weight than they have under the current system, would help to solve that problem and improve care for thousands of people.
I will give a quick practical example for anyone who needs it. Medication for schizophrenia has improved dramatically. Some of the medication that mum used to take would cause regular, sustained vomiting, which caused teeth loss and worse. Different treatments are available. If she were sectioned and put back on that medication, knowing the side effects, it would obviously make the treatment worse for her. I hope that the Minister will give a strong indication about the Government’s plans for advance decisions and the ability to make choices that can improve the treatments available.
When a person is detained under the Act, they have a “nearest relative” who has certain rights to be involved in their care. Many family members and patients value the fact that relatives are given a statutory role, but that relative is chosen from an outdated hierarchal list that is based on age, rather than on the views of the individuals involved or on whether they have a good relationship. The Government accepted that recommendation from the review. I hope that the Minister will have more to say about that today—[Interruption]—and less about stopping Brexit, which is the chant outside that may have been caught on the microphones.
Those who are detained under the Act have effectively no legal say over their treatment and no automatic right to advocacy in the event of their detention. The fact that such rights are not enshrined in the legislation illustrate that reform is badly needed. Establishing a right to an advocate for all mental health in-patients, whether voluntary or detained, without having to ask for one, would also radically improve care, as would the statutory inclusion of a patient’s advance wishes in their treatment plan. I hope that the Minister will give an indication on that matter today as well.
I will cut down the bit of my speech about resources, because they have already been mentioned and I know that other hon. Members want to speak. However, cuts have had serious implications, including for the distances that people, including children, have to travel for treatment: they are often taken hundreds of miles away from their friends, family and community. That cannot be acceptable. Wider cuts to council budgets and the public health agenda have also had an impact, and my constituency has experienced the knock-on effects. We lost an organisation called CoolTan Arts, which used to provide creative and employment support for many disadvantaged people with mental health conditions.
My very real fear is that the bad old days have crept back. For too long, Ministers have ignored the problems. There have been cuts to services, and we are seeing more ill-trained or morale-sapped staff; an overuse of agency crews; rising use of detention, which locks the problem away out of sight; and compulsion rather than empowerment. That must change. The new Prime Minister must listen to what is said in this debate; I hope he will. The White Paper that has been promised must be delivered and must reflect the spirit and ambition of the independent review.
New legislation must also be passed to update the Act. It is not just about getting a better piece of legislation; more importantly, it is about better treatment for the thousands of people with mental health conditions and their families up and down the country. There is cross-party support for this work: 49 colleagues have signed early-day motion 1242, which
“calls on the Government to reform the Mental Health Act…during this Parliament”.
There is appetite in the Commons for that reform, so I hope it will be delivered.
We have a window of opportunity to improve thousands of people’s lives. I hope that the Minister and the new Cabinet and Government will take it.
While I was doing the research for that debate, it was drawn to my attention by staff at acute units that their particular nightmare was the thought of what would happen if there was inadequate staffing coupled with mixed-sex wards. I was really rather shocked and shaken today to hear the statistics cited by the hon. Member for Bermondsey and Old Southwark about the level of danger of sexual assault among in-patients, because for quite a number of years I and various other colleagues waged a campaign to abolish mixed-sex wards in mental health in-patient facilities. At first there was talk of separate bays, if I recall correctly, which by no means would have answered the necessities of the problem. And successive Governments kept saying that they would do it, and even that they had done it, so it is particularly disturbing to hear about the level of concern that still exists about this issue.
The question of inadequate numbers of beds has already been touched upon by the hon. Gentleman. It has to be said that, for once, this is not the responsibility or fault of Government, because after the closure of so many of the large asylums, the pendulum—in my opinion, and I am not an expert; I have to say that I am not a medical doctor—swung too far the opposite way.
I remember, in the New Forest area, having to fight a bitter campaign—which ultimately failed—to prevent a 35% reduction in in-patient beds in acute units. If I remember correctly, two of five units were closed. We were prepared to compromise and say, “Close one of the two units. Close 16 of the beds, rather than 32, and see how you get on,” but the authorities would not listen and they forced the closures through. It was the Southern Health NHS Foundation Trust, which later became notorious in the mental health sphere for other reasons, that forced through the closure of all these beds, and the system has been rammed and overflowing, and under excessive pressure, ever since.
There was another knock-on effect of the swinging of the pendulum too far back from the correct policy of closing the larger asylums, and that was that, by having fewer permanent facilities, we lost the ability to have what was technically—or maybe not very technically—known as the “revolving door”. This was the idea that, yes, if we could get more people back in society, so that they could make their own way and live their lives freely and without having to be in-patients, the very existence of a network of permanent establishments—albeit for other purposes—meant that there were always plenty of opportunities, so that if somebody felt that a trough was coming they could seek help easily for, as it were, almost a top-up of treatment, just for a few days. That would then set them back on track and it meant that they would not suffer—
It subsequently turned out that there were very good guidelines that said that such information should be shared. So, I wrote to the then Minister with responsibility for care services, the hon. Member for Bury South (Mr Lewis), saying that there was clearly a breakdown in the system if adequate rules existed but were not being put into practice locally. The rather unsatisfactory answer that I received at the time was that the responsibility lay with the local medical authorities to ensure that the central guidelines were implemented.
As I say, that was at the end of 2010, so it was a long time ago. I wonder whether the Minister will be able to reassure me that there is now more central direction. In the case of Lara and her parents there was inadequate sharing of vital information, under the mistaken belief that patient confidentiality trumped the fact that an adult patient was incapable of making her own decisions. I would like to know whether that situation has been rectified, or whether we are still dependent on local medical institutions and authorities to apply a central guideline that ought to be better known.
This week, I received a letter from Lara’s mother, who asked me to attend this debate. I can do no better than to read from what she says, not so much about what happened to her daughter but about the continued interest that she has in the workings of the mental health services. She says that she would like to make her own recommendations; given what happened so tragically in her immediate family, we owe it to her to give serious consideration to those recommendations, which are as follows:
“1. The 1983 Act should be revised to prioritise the dignity of individuals who come to be in the Service’s orbit.
2. Such individuals should have their values and world views respected and have a significant say in the manner of their treatment.
3. They should have the option to refuse certain treatments.
4. Mental hospitals must be places where patients feel safe: there have been numerous allegations of staff members being abusive, provocative and/or intimidating.
5. Use of force should be absolutely minimised. This includes physical restraint, seclusion, or forced medication.
6. A reduction in ‘sectioning’.
7. A reduction in stigma”—
and finally:
“8. All aspects of the Mental Health Service should be more open, and subject to independent scrutiny from time to time.”
I will conclude by making one left-field observation relating to the armed forces. The Select Committee on Defence, which I have the honour of chairing, has been recommending for some time that we establish a centre of excellence for the mental injuries suffered by those who put their life on the line to defend this country, preferably alongside the national centre for physical rehabilitation at Stanford Hall. We have now raised this issue twice with the Secretary of State for Health and Social Care, who has given us a reasonably encouraging response. However, once again, we feel that he is coming up against resistance because of the philosophy that people must be treated locally when at all possible, not admitted as in-patients in centralised locations. That is causing a pushback against our idea.
Our idea is based on the fact that those who suffer injury in combat situations have experienced a peculiar and unique form of trauma, different from those that ordinary mental health professionals can be expected to understand. I am sure that my hon. and gallant Friend the Member for Plymouth, Moor View (Johnny Mercer) will want to expand on that topic, if he is lucky enough to catch the Chair’s eye. We believe that there is a case for a national centre of excellence, and that the welfare of members of our armed services who suffer mental injury should be no less important to us than the welfare of those who suffer other, physical forms of injury in the cause of defending our freedom.
Under the Act, people with learning disabilities and autism can be sectioned with no mental health diagnosis if they are displaying challenging behaviour. The independent review found that the Mental Health Act was
“being used inappropriately for people with a learning disability, autism or both, to deal with a crisis that has arisen because of a lack of good community care or placements…It is particularly intimidating for a person with autism, learning disability or both to be removed from a place they are familiar with or from people they know, even if at the time there seemed little alternative…Instead of improving their mental health, the environment (including relationships with staff) has made them worse, not better.”
One of the common characteristics of autism, for example, is being wedded to routine, and being uncomfortable with unfamiliar circumstances and stimuli that those people would perhaps not get in a more protective environment. That can be particularly challenging.
The Equality and Human Rights Commission echoes such concerns, stating:
“The Commission is concerned about the lack of suitable provision for people with learning disabilities and autism, who may be in restrictive institutional settings because there is insufficient community-based support. The Government failed to meet its minimum target to reduce the number of people with learning disabilities and autism detained in inpatient settings, and at the end of March 2019 there were still 2,260 children and adults living in these institutions. On average, they had spent almost 5 and a half years detained away from home. There were more than 2,600 restrictive interventions recorded against inpatients with learning disabilities and autism in a single month, including physical, chemical and mechanical restraint, seclusion and segregation. Of these, 875 interventions were used against children.”
Most of those people should never have had to go into an in-patient unit, let alone be subject to those types of restrictive intervention. They are ending up in such units because of challenging behaviour due to unmet needs in the community. Those needs, as I have said, should be met with vital investment in community mental health services.
From my experience of people who have come to my surgeries, other casework that we have been dealing with and what I have picked up from visiting institutions, it seems that mental health services suit certain people because of the pathways developed in the NHS, but others do not fit into that category. For example, a child with learning disabilities was rejected for anxiety counselling, and they were later diagnosed with autism. To do the standard CAMHS anxiety counselling, someone has to have a certain ability to rationalise their actions and think about how they operate. That cognitive behavioural therapy-type approach was not suitable for that child, but that meant that nothing was available, because that was the pathway for young girls suffering from anxiety.
I had another case where a constituent was told that she was too traumatised by a recent experience to go through the counselling on offer through her GP. She clearly was not in a serious enough condition to be sectioned, however, so it seemed like she was caught between two things. She clearly needed help, but she was deemed to be too serious a case to get the help that was available. We need to look at the people, rather than just trying to fit them into categories and, when they do not fit into categories, rejecting them from the system, almost as though we are saying, “Come back when you are a lot worse, and then perhaps there is something we can do for you.” That has to be the wrong approach.
Going back to children in particular, the UN Committee on the Rights of the Child has expressed specific concerns about the adequacy of therapeutic community-based services for children. Because of that lack of community provision, children are being detained when they should not be. According to NHS Digital, at least 1,777 people aged 17 or under were detained under the Mental Health Act in 2017-18. Of those, more than a thousand were admitted to a non-local bed, in many cases more than 100 miles from home. Some children and young people under care of Bristol, North Somerset and South Gloucestershire CCG had to travel up to 243 miles away from home for mental health care. That cannot be in the child’s best interests and will add to the sense of isolation and anxiety, and it can also prevent their families from being properly involved in their care.
A recent Children Commissioner’s report found that many parents feel they are being shut out of decisions about their children’s care and are not always informed about incidents involving their children. Serious incidents had happened in hospital without families even being told. Some families had even faced gagging orders where they had been prevented from speaking out about their children’s care. The independent review calls for better safeguards to protect children and young people, ensuring that they are treated in hospital only when necessary and that their rights as a child are clearly set out. There is a need to establish clear tests as to whether children and young people are able to consent to hospital admission or treatment and whether they should be involved in decisions made about them. Clear roles need to be established for parents in care planning and treatment.
The review also states that there needs to be more advocacy available for children and young people. That is particularly important where conflicts arise between the clinical team about how to meet the best interests of the young person, including where contact between young people and their parents is seriously restricted—in some cases, the mental health crisis might be the result of chaotic family circumstances at home or ill treatment—or where the wishes of the young person conflict with the wishes of the adult.
Every in-patient child or young person should have a personalised care plan that includes their views and wishes and access to an advocate. They should be regarded as a child in need under the Children Act 1989 so that parents can ask for help from their local authority.
As the British Medical Association lead for mental health, Dr Andrew Molodynski has said:
“Warehousing unwell people in locked wards far from home goes against the very nature of mental health rehab—to help them reintegrate back into society.”
Unnecessary detention of vulnerable patients is not only unhelpful in terms of their recovery, but an ineffective use of taxpayers’ money. Too much money is being given to private firms to look after people with serious mental health problems in units often hundreds of miles away from their homes due to a shortage of NHS beds. That figure was £158 million in 2016-17 and £181 million in 2017-18—an increase of £23 million.
Last year, an extensive study of mental health rehabilitation by the Care Quality Commission found that stays in private beds cost twice as much as in the NHS because they tend to last twice as long. It found that the annual cost of rehab was £535 million and that private beds were on average 30 miles away from patients’ homes, whereas in the NHS they are only nine miles away.
One of the cases that I have been dealing with recently is that of a child who is in a mental health unit 150 miles away from home, but the unit closest to her home is in special measures and not accepting new patients. However, the unit she is in is ranked as outstanding and she seems to be making good progress. Clearly, when parents are faced with such a choice, they want their child to go to the best unit possible, but that can put huge pressures on a family, in particular when they have other children, as well as jobs and lives. They might also not have the money to decamp to somewhere so they can visit their distressed child each day. There is a real lack of support in the system for families placed in such circumstances, with their whole lives disrupted by trying to be in two places at once.
Another problem is that the quality of care in hospitals can be highly variable. The Whorlton Hall case demonstrated just how awful situations can be, and how badly people can be treated in some places. In a recent investigation into children with learning disabilities or autism living in mental health hospitals, some families told the Children’s Commissioner about the excellent support that their children had received—it is important to put on the record that there is good care out there—but others had shocking stories to tell. For example, one family said that their son had not been washed for six months while in hospital. Basic care needs were not being met.
Despite improvements in recent years and the drive towards parity of esteem between physical and mental health services, it has not been realised. The aspiration is noble and shared by both parties, but we need to invest far more in our mental health services for people to get the support they need. I welcome the fact that the need for better community services was highlighted in the recent NHS long-term plan, and I am pleased that the Government have committed more funding to severe mental illness and to greater use of alternative mental health crisis provision, such as crisis cafés. However, an overhaul of the Mental Health Act is clearly needed if that investment is to be used in the best interests of patients by ensuring that their dignity and rights are protected and that they are treated in hospital only as a last resort.
The previous Prime Minister committed to new legislation to bring the Mental Health Act into line with a more modern understanding of how best to treat mental health. She confirmed that a White Paper would be published before the end of the year. The Minister is probably wondering whether she will be in post by the end of today, but even if she is moved on to greater things, I hope she asks the new Prime Minister to give that the same priority as the previous Prime Minister did.