Mental Health Bill [HL]

Committee (5th Day)

Amendment 130

130: After Clause 50, insert the following new Clause— “Cost and implementation reporting(1) The Secretary of State must lay a report before Parliament four months after the passage of the Act, and annually thereafter, assessing the costs and implementation dates of provisions in the Act.(2) The report must include details on—(a) the monetised and non-monetised costs to the health and social care system;(b) the monetised and non-monetised costs to the justice system;(c) costs associated with additional training for NHS staff responsible for treatment provisions;(d) costs related to community care services and infrastructure;(e) costs for additional training for approved mental health practitioners and independent mental health advocates;(f) additional costs incurred by local authorities;(g) housing and care-related costs for individuals with autism or learning disabilities; (h) additional costs incurred by the Care Quality Commission;(i) costs for training responsible clinicians and other relevant parties involved in patient care.(3) The report must also include a monitoring and evaluation strategy for the reforms introduced by the Act, including—(a) commencement timelines for the Act’s provisions;(b) an assessment of the Act’s impact on patient outcomes including user feedback; (c) relevant data to evaluate whether the reforms are being delivered as intended;(d) assessments of the impact of new safeguards and support mechanisms on patient and carer experiences.(4) Following the publication of the first report, the Secretary of State must arrange for the tabling of—(a) a motion for resolution on the report in the House of Commons moved by a Minister of the Crown, and(b) a motion for the House of Lords to take note of the report moved by a Minister of the Crown.(5) If the report is rejected by the House of Commons, the Secretary of State must deliver a statement to Parliament within a period of three months which addresses the contents of the report.(6) Subsequent reports are not subject to the provisions of subsection (4).”Member’s explanatory statement This amendment requires the Secretary of State to present a report to Parliament detailing the costs and implementation assessments of the Act after one year, and annually thereafter. The first report published under this provision must be subject to a resolution motion in both Houses of Parliament.

My Lords, I rise to speak to Amendment 130 in the name of my noble friend Lord Scriven, who is unable to be in his place today. On these Benches, our view is that this amendment is essential to the success of reforms proposed in this Bill. It would ensure not only accountability but the continuous assessment of costs and implementation timelines related to the vital provisions of the Bill. In short, it is a costed plan. It is grouped with various other important amendments, some of which I strongly support.

The issue we have repeatedly encountered in both mental health policy and community care is that we end up with community but very little actual care within it. This gap leads to preventable health crises, placing individuals and services under immense strain. Therefore, we must do everything to avoid this outcome. Yet so far in Committee we have not heard the necessary reassurances that adequate provisions will be in place nor that they have been properly costed and strategically planned for community care.

At its core, this amendment champions the need for transparency in the investment and execution of mental health care, specifically within community settings, where the demand will be greatest when the changes in legislation are brought forward. We cannot afford to enact these mental health reforms without a clear understanding of their financial and structural impact on the health and social care system, the justice system, local authorities and, most importantly, the lives of those who rely on these services.

In short, the amendment would require the Secretary of State to lay a report before Parliament within four months of the passage of the Bill and annually thereafter. The report would provide a detailed assessment of both the monetised and non-monetised costs associated with the provisions of the Bill. Specifically, it would outline the financial commitments necessary for the training of NHS staff and approved mental health professionals, the expansion of community care services and the provision of adequate housing and care for individuals with autism or learning disabilities. Furthermore, the amendment would ensure that the Care Quality Commission was adequately resourced to uphold the highest standards of mental health provision. These are fundamental requirements, because without a clear cost framework and implementation plan, we risk leaving individuals in crisis without the support they need.

My Lords, in speaking chiefly to my Amendment 153, I shall say briefly that I very much agree with what the noble Baroness, Lady Tyler, just said and support, as does she, the related amendments that come after this. They interrelate with an amendment of mine that was discussed earlier in Committee about the funding of community services. Funding is the great issue right across the board, and it is essential that there is something in the Bill that addresses that. My amendment, although it looks somewhat different from the others in this group, is closely related to them, because, as the noble Baroness said, we have to be concerned about the implementation of the Bill and not just its nature.

My amendment says that for-profit companies should not deliver under the Bill. It does that in two ways. It says:

“Any new facilities or organisations created to deliver the provisions of this Act must not be operated by for-profit companies”.

It then says that within five years of the day on which this Act is passed, the Secretary of State must ensure that what is now for-profit in this space is transferred to not-for-profit. Why is that essential to implementation? I shall put it into three categories.

The first is the cost of paying profits from what should be money for the provision of services. The second is quality issues associated with for-profit companies; after all, their directors and management have a duty to maximise the return to shareholders. That is the way that for-profit companies are set up in this country. The third is that there are issues of stability.

I will go into those in a little more depth. I suspect it will surprise many members of the public to know that, last year, the NHS spent more than £2 billion on private mental health hospitals. That is a £279 million increase on 2023, reflecting the decades of cuts in beds. This is not a competitive market situation. The two biggest providers, the Priory Group and Signet Healthcare, generated £509 million and £560 million in revenue last year and account for more than 68% of what is being described as the market in our private healthcare.

There have been many reports expressing concerns about the level of services. I am not going to run through a long list of them, but I am sure noble Lords in this Committee are well aware of those issues. There is also the issue that many patients are being placed into out-of-area placements. Facilities are being set up in places that are cheap to run but are not necessarily in the vicinity of patients’ homes and families and the kind of social set-up that might support them.

It is interesting to note, in the context of our whole private healthcare sector, that the majority of the private hospital sector’s profits comes from NHS patients. There was £2.34 billion spent on mental health in 2023, compared to £3.5 billion on in-house NHS beds. That is very costly, and there are quality problems and a huge stability issue. In the middle of last year, a leading provider of private mental health services narrowly avoided liquidation. This is an issue that we have also seen in our care home sector on multiple occasions. We are seeing ownership with private equity, which is based on a model of heavy loads of debt. Quite unsurprisingly, we are seeing significant rises in interest rates after a period of long-term low interest rates recently, and that has created instability in the sector.

So what happened in the middle of last year? An administrator was appointed on 29 May for the Active Care Group, which cares for hundreds of vulnerable patients in the NHS. The financial problems had been going on for months—they can be dated back to the end of 2022—and people within the company were aware of them, but it was only in that month that NHS England finally heard about it. NHS England immediately ordered ACG not to take on any new patients and ordered it to provide daily updates to it on the situation. Eventually, a rescue was carried out, but this is instability that we cannot afford to have. The whole foundation simply does not work if we have a handful of private companies dominating our services, not providing good-quality care and not providing care where it is needed.

I am aware and have to acknowledge that the general response will very much be: “We’ve got ourselves into this mess. How do we get out of it?” The reason I have put forward this amendment to the Bill is to say that we have to acknowledge that this is an unstable and inadequate position: people are not getting the care they need and patients are not being cared for. We need to set out a road map to get to a different situation where we have healthcare delivered for the good of the public—the patients and the whole community—not for private profit.

This amendment sets out a road map. I am not saying exactly that we do not have the power in your Lordships’ House to say how the Government should spend money, but this amendment sets down a principle that says that we have to move in this direction.

My Lords, building on many of the important points we have just heard, I will speak to Amendments 163 and 164 in my name. I thank the noble Baronesses, Lady Tyler of Enfield and Lady Neuberger, and the noble Lord, Lord Kamall, for their support for these two modest proposals, which are parsimoniously drafted but nevertheless potentially impactful if adopted.

The first amendment quite simply says that we will do away with “mañana, mañana” when it comes to implementing this Bill, which we have all spent so much time on and which the patients and advocates are so keen to see adopted, by putting a five-year backstop from the date on which the Bill becomes an Act through to commencement. Commencement of all its provisions must happen no later than five years after the Bill receives Royal Assent. The logic for that is that we all believe that, on balance, by the time the Bill has worked its way through Parliament, it ought to be an injection of improvement for mental health services, so why would we want to delay?

Of course, part of the answer is that there are some rate limiters, which are described elsewhere, including in the impact assessment. If we go through the impact assessment and say, “All right, what are the specific things that it suggests won’t be possible or won’t have got going until year 6 after Royal Assent?”, we will find it is a relatively modest number. For those who want to take a look, it is in table 1 of the impact assessment, at page 17. There are some changes to the second opinion doctor, to the CTOs, to the CTPs and so on, but both the pound note impact and the extra staffing at year 6 and beyond are incredibly modest compared with the overall size of mental health spending that we will incur. The incremental costs beyond year 5 are somewhere between £15 million and £25 million, on a budget that runs to billions. I believe that, in the real world, if we strain every sinew, it will be possible to get this thing done within five years.

My Lords, I apologise for my absence from earlier debates in Committee. I will speak very briefly in support of these amendments. My noble friend said that we need to save ourselves from ourselves. Actually, we need to raise aspirations to change the culture of believing that it cannot be done and thinking that it will cost too much to take a more preventive approach, to care properly for people in the community and to achieve parity for mental health outcomes. These amendments are really important to try to achieve that, so I support them.

My Lords, I will speak very briefly in support of Amendments 163 and 164, to which I have added my name, and particularly about the length of time, the five years.

We first started talking about the reforms to the mental health legislation eight years ago, when we set up the review of the legislation under Sir Simon Wessely, and I was the vice-chair. It reported in 2018—seven years ago—and it was not even a very radical rethink of our mental health legislation. Yes, it will make a lot of difference to a lot of people—service users are very keen for this to come about, and they certainly do not want to wait longer than five years to see all the measures come into force—but this is relatively gentle stuff. At some stage we will need a much more radical rethink of our mental health legislation. Five years is quite a long time, so I rather hope the Minister can give us some comfort by saying that most of it will be done in two years, or perhaps three years at the outside.

My Lords, first, I support Amendment 130 in the name of the noble Lord, Lord Scriven. I have been concerned, as we have discussed this Bill, that costs are likely to spiral. I am not objecting to that, but it seems to be the elephant in the room. Unless we know, the Bill will become a white elephant because people will just say that we cannot afford to do it. It is far better to have transparency, as has been argued.

Secondly, I oppose Amendment 153. For a number of reasons, I do not think we should prohibit for-profit entities being involved in this endeavour. The suggestion is that if we remove the profit motive, all will be well. A word of caution: not-for-profit organisations are not necessarily the most efficient, virtuous organisations, as we might imagine. In the charitable sector there are some worrying trends of money being spent, rather self-indulgently, on staffing and on all manner of extraneous and sometimes politicised endeavours.

We have seen the emergence of EDI—equality, diversity and inclusion—policies, which the Health Minister, Wes Streeting, has worried about happening in the state sector, and we have seen them become absolutely rampant in the charitable and not-for-profit sector. I want us to concentrate on the people the Bill is designed to help and therefore not to have our own political idea that only the state can deliver well—I just do not believe that is true.

For example, I have done work in prisons over a period of time—that also relates to the Bill—and have worked in both private and state-run prisons. Some private prisons are awful and some state-run prisons are worse—and, by the way, I have worked in some brilliant state-run prisons and some brilliant privately run prisons. We should judge on the basis of the quality of the care or the service that they provide, not some prior presumption that because they make profit they might be useless, somehow evil or not attending to their core mission.