My Lords, it is an honour to move the Second Reading of the Mental Health Bill—a Bill which Members of both Houses have been waiting for and working on for some considerable time.
There is much consensus that our mental health laws are not fit for the 21st century. Many elements of the Mental Health Act 1983 are outdated. Its operation is associated with racial disparities and poor care for people with a learning disability and autistic people, and it fails to give patients an adequate voice. Modernising the Mental Health Act is a vital manifesto commitment for this Government, so I am proud to introduce reforms that will ensure that care is appropriate, compassionate and effective; give patients more say over their care; improve support to help patients understand and exercise their rights; and protect the safety of the public, staff and patients.
The wait has been too long. I know that a number of noble Lords were involved when the Act was last amended substantially in 2007, but, although attitudes to mental health have, thankfully, changed since then, the law has not kept up. The Bill is the product of the combined effort over some years by Members of both Houses and many outside Parliament, and all parties have rightly come together to support it. Sincere thanks are due to many, but I will highlight just a few, starting with Members of your Lordships’ House who served on the pre-legislative scrutiny committee in 2022: the noble Baroness, Lady Buscombe, as chair, as well as the noble Baronesses, Lady Barker, Lady Berridge, Lady Hollins and Lady McIntosh of Hudnall, and the noble Lord, Lord Bradley. All have given a huge amount of time, expertise and energy, which has informed and motivated this Government to strengthen the Bill. I confirm that we have improved the previous draft Bill by heeding the committee’s recommendations to include guiding principles and advance choice documents in this revised Bill.
I pay tribute to the former Prime Minister, the noble Baroness, Lady May, whom I had the pleasure of meeting earlier today with the Secretary of State. The noble Baroness, Lady May, identified the need for modernisation and set up the independent review of the Act in 2017. Without this, we would not be here today. I thank the independent review chair, Sir Simon Wessely, and his vice-chairs, including the noble Baroness, Lady Neuberger, who made the case for change and provided the blueprint to follow. I know they will continue to be champions for reform. I also thank the many stakeholders and parliamentarians who have engaged with us ahead of Second Reading and over the years, and those with lived experience, who have bravely told their stories.
The Bill will complement other major reforms that this Government have announced. The Budget announced £26 million to be invested in new mental health crisis centres to reduce pressure on accident and emergency departments. To cut mental health waiting lists, we will go further still, recruiting an additional 8,500 staff. As part of our mission to reduce the number of lives lost to suicide, these NHS workers will be specially trained to support people at risk. We will improve support for young people, with walk-in hubs in every community, making support workers more accessible to children, and a specialist mental health professional based in every school. The NHS has asked every provider of mental health services to review its offer for serious mental illness. By focusing on early intervention—prevention is the key—we seek to prevent people reaching crisis and to reduce the need for detentions in the first place.
My Lords, I begin by extending my gratitude to the noble Baroness, Lady Merron, for introducing the Bill into your Lordships’ House and for her very clear exposition of its contents. It is a Bill that we on these Benches warmly welcome. That welcome should not come as a surprise because, as the noble Baroness said, the Bill before us is the successor to a draft Bill prepared by the previous Government, a draft that owed its origin to my noble friend Lady May, on whose watch a review of the 1983 Act was initiated some seven years ago during her time as Prime Minister. Much of what we see laid out here is the product of diligent work carried out by Professor Sir Simon Wessely and his review committee, as well as the Joint Committee of both Houses, so ably chaired by my noble friend Lady Buscombe.
The passage of the Bill presents us with a golden opportunity to address both the current state of mental health provision and the law that governs it. The last major update of the Act took place in 2007 under the previous Labour Government. That may not sound like a long time ago but, as we shall no doubt hear from others, experience gained in the intervening years has taught us that a further update is indeed warranted if we are to ensure that the Act remains relevant and appropriate, and that its powers are proportionate.
Wherever the state uses its powers to deprive an individual of their liberty, the necessary safeguards must be in place so that those powers are used sparingly, proportionately and with the highest regard for human dignity and autonomy. That is why the Bill is so important. Since the last set of changes to mental health legislation in 2007, the number of people being detained under the Mental Health Act has grown exponentially. In fact, since 1983, the numbers have nearly doubled to a total of over 52,000 new recorded detentions between 2023 and 2024.
Within that total, we have also seen a stark disparity in the classifications of those being detained. Black people are 3.5 times more likely to face detention under the Act. Shockingly, to my mind, there are currently over 2,000 people with autism and learning disabilities detained in mental health hospitals across the country. I was equally shocked by the realisation that people with autism can be detained even if they do not have a mental health condition, leading to disproportionate, burdensome and wholly inappropriate treatment.
My Lords, I declare an interest as a member of an advisory panel for Rethink Mental Illness.
The House of Lords is an institution that is frequently criticised. Those of us who are often called on—not least by schoolchildren—to defend it often find ourselves having to give examples of work it has done which would not have been done by anybody else. As a veteran of the pre-legislative and post-legislative scrutiny of the Mental Capacity Act, the pre-legislative scrutiny of the Mental Health Act 2007 and all the various bits of subsequent legislation, I think that we have arrived at the point with this piece of legislation where we can make a defensible case for the unique contribution of this place to legislative progress. As the noble Baroness, Lady Merron, was generous enough to say in her introduction, there are a lot of us in this place who have got form on this. Specifically, there are an awful lot of us who have detailed knowledge of all those bits of legislation and of the workings of the 1983 Act.
If the noble Baroness will not mind me saying, we come to these pieces of work in two minds. It is great to have the opportunity to go back, look at what we did in the past and rectify some of the mistakes. However, it is always also deeply frustrating because, in truth, here we are again putting another patch on the 1983 legislation. We will never get the mental health system that we so badly and desperately need until we do more than that.
Having said that, along with other noble Lords, I congratulate Sir Simon Wessely and his team, and specifically the working groups that worked with him. If any noble Lord who has been inundated with briefings from all the interested parties, as we all have been, is ever in doubt about a subject, they should go back to the report of the working groups to understand how people have arrived at their conclusions and what we should perhaps strive for. I say that as the person who sat here night after night during the passage of the 2007 legislation, arguing for an advance choice document against a lot of entrenched opposition, not least from practitioners. It is really important that we use the privilege of our position—I mean that: privilege—to work away at this legislation as we did with that so that, perhaps uniquely, we can make some progress.
My Lords, it is a pleasure to follow the previous three speakers. I declare my interests as a non-executive member of the NHS England board and 45 years as a registered mental health nurse.
I warmly welcome the long-overdue reform of the Mental Health Act and congratulate the new Government on bringing it swiftly in their term. I appreciate the opportunity that the Minister has taken in holding discussions about the Bill prior to Second Reading and offering to consult further about potential amendments to strengthen and clarify particular sections. Modernising the 1983 legislation provides a real opportunity to reduce injustices in implementation and provide equitable support for people suffering from a mental health crisis, giving them more autonomy and choice and including a new right for service users to choose a nominated person to advocate for their interests.
First, I am pleased that the Bill aims to end the unnecessary detention of those with autism or learning disabilities, yet I share the concerns of the Royal College of Psychiatrists and other professional bodies that further clarity is needed around assessment and treatment. For many, the proposed 28-day limit for assessment may not be long enough to reach a comprehensive diagnosis, especially considering that those with autism often present with additional complexities. It may be difficult to admit, assess and support some patients within the time limit outlined in the Bill, risking recurrent use of overstretched A&E or admission and detention under Part III of the 1983 Act should there be safety concerns. The NHS Confederation drew on the example of New Zealand, where similar changes to mental health legislation saw a temporary increase in patients being sent
“to prison, left neglected in the community or admitted to forensic facilities as secure patients”.
My Lords, I am grateful to be able to participate in Second Reading of this important Bill. It is a privilege to follow the noble Baronesses, Lady Barker and Lady Watkins, who have a real breadth of experience in this field. I too welcome, along with many noble Lords, the reform of the Mental Health Act, which is long overdue.
The noble Earl, Lord Howe, highlighted the over-representation of minoritised communities detained under the Act but also placed on community treatment orders. Some groups are also more likely to be detained through contact with the criminal justice system or emergency departments. It is important to remember that we are speaking about these inequalities in the wider context of health inequalities; some groups present to health services far later, when their symptoms have worsened. The Royal College of Nursing notes in its briefing that mental health services are
“not seen as accessible to all communities”,
and that:
“Many black men have a first interaction with a service via the police during a crisis”.
Many of the organisations that have helpfully sent briefings ahead of the debate have acknowledged that the legislative actions available to address this issue are limited. The Minister highlighted the advanced choice directives, which are a welcome step towards this. As the Joint Committee on the Draft Mental Health Bill notes, this is important for those who have experienced trauma, disempowerment and discrimination.
Data collection has also been discussed during scrutiny of the Bill. Although data collection is improving, capturing more complex data on ethnicity is important when looking at health inequalities in this way. In much of the work I have done on health inequalities with the NHS and faith groups, ethno-religious identity is significant if communities are to be better understand at an ICB level or higher how to reduce inequalities.
My Lords, I refer the House to my interest as a vice-president of the National Autistic Society, a role I share with my good and dear friend, the noble Baroness, Lady Browning.
I welcome the Bill. It has been a long time coming, and I passionately hope that it will allow us to end once and for all the myth that autism is a mental health condition. Autism is most definitely not a mental health condition, and our failure to address this has meant decades when autistic people have been wrongly incarcerated, often in appalling and degrading conditions, and robbed of their human rights. More than 2,000 autistic people and people with a learning disability are in mental health hospitals in England, a point made by the noble Earl, Lord Howe, in his opening remarks. The National Autistic Society tells us that 68% of these people are autistic.
Some 93% of autistic people and people with a learning disability in mental health hospitals are detained under the Mental Health Act 1983. The average length of stay is five years, but for a great number of autistic people the detention lasts for decades. Professor Sir Simon Wessely’s review of the Mental Health Act in 2018 found that the experience of detention was often damaging and traumatic. The Bill includes measures to improve care and support for autistic people, reducing reliance on hospital-based care. That certainly is good and is welcomed.
However, there are aspects of the Bill that concern me, and I have had a chance to discuss them with my noble friend the Minister. I have been fortunate to have had a number of fruitful meetings and discussions with a team from the Autism Centre of Excellence at Cambridge and, as a result, they and I share some concerns. First, the Government have said:
“For those with a learning disability or autistic people, the act will be amended to place a limit of 28 days for which they can be detained unless they have a co-occurring mental health condition”.
My Lords, it gives me enormous pleasure to speak in this debate. For me, this legislation is above politics: it is a real opportunity for constructive opposition. I welcomed the call in July from the Secretary of State for Health, Wes Streeting MP, asking whether I would support the Bill and assist in its progress. Yes, there are some aspects of the Bill on which we on these Benches will wish to press the Government. However, our view is that it is overdue and critical for so many people who have felt misunderstood and suffered serious neglect for too long.
I feel lucky to have chaired the Joint Committee on the Draft Mental Health Bill. Everyone on the Committee apart from me had professional and practical expertise and experience and/or powerful personal experience and knowledge through friends and families. We received evidence from more than 50 organisations and many people who were service users, to whom we remain eternally grateful. We had many hours of strong debate and always managed to find a way through. Results sometimes involved compromise but were also consensual. I thank each and every member for their invaluable contributions, together with our advisers and the brilliant Alex Ruck Keene KC for his extraordinary drafting skills. I also thank the clerks and officials who worked skilfully against a very strict timetable.
I pay tribute to all our medical staff who work in this complex and, in many ways, challenging field of medicine. My sincere admiration for them, and the difficult choices and decisions that they must make, knows no bounds.
A key point for me—I speak as a lawyer—is that so much that directly affects the well-being of patients must be improved, not necessarily by legislation, which can hamper positive change, but through a step change in culture in order to genuinely value every individual and improve their life through choice, dignity, support and advocacy. The Bill seeks to address that, although it lacks a key tool: the use of technology and the drive for data, which I urge the Minister to consider.
My Lords, this is a long-overdue Bill, as many have said, and I hope it will progress through the House as quickly as possible. Quite why it has taken six years for Sir Simon Wessely’s report to be acted on, I am not sure, but I am particularly pleased that we have got advance directives in, even if in a slightly watered-down form.
However, there are some rather troubling changes that have been squeezed in recently for reasons that are difficult to understand, and I shall want to explore those in Committee. There are differences between the criteria for Parts 2 and 3 of the Bill, for example, which is bizarre, and I am scared that the changes in relation to learning difficulties and autism, in spite of all the good intentions, will be extremely difficult to implement. Throughout the Bill, there is an assumption that if you change the legislation, it happens, but we know very well that it does not—it takes years to implement—so I am concerned about that overall. Having said that, I will remain on the theme that the noble Baroness, Lady Barker, picked up. We will leave the rest until Committee, where we are going to have very detailed debates.
It is now 20 years since I came into this House with the certainty of the optimistic new girl that we would see a new mental health Bill that addressed the deeply flawed legislation that we had been living with since 1959, but I am pretty sure now that I shall leave the House having seen no fundamental change. I am ashamed that in England and Wales we are falling so far behind many other countries, when we used to be in the advance in devising mental health law that was fit for purpose. Scotland is 20 years ahead, as is Northern Ireland.
I was told back in 2017 by Simon Wessely and others that it would take 10 years to develop a unified mental health and capacity Bill. If we had started then, we would be almost there by now. We tinkered with the 1959 Act in order to produce the1983 Act. We added a new Mental Capacity Act in 2005 that cut across mental health legislation. Then we added the ludicrously undeliverable deprivation of liberty safeguards and added tiers of bureaucracy to an already overburdened system, all reducing the time for clinical and social care professionals to spend with patients as they had to spend more time filling in forms. The new Bill makes no attempt to address the complicated relationship between the 1983 and 2005 Acts or how they are meant to be used for individuals, and this is particularly difficult for patients with learning disability and mental disorders and also older people with dementia where people are tossing up which Bill is going to be used. It is clinically ridiculous.
My Lords, it is a great pleasure to be able to contribute to the Second Reading of this very important Bill, albeit, as other speakers have already said, a Bill that has been too long coming. I wholeheartedly welcome this Bill and I thank the Government and commend them for bringing it forward so quickly in their term of office. I also thank the noble Baroness the Minister and the Secretary of State for the meeting that they held with me earlier today. Like others, I also want to look back and thank Professor Sir Simon Wessely and his team—including, not least, the noble Baroness, Lady Neuberger—for the invaluable work that they did that has led to the Bill before this House today. I want to say a particular thank you to those with lived experience who were willing to come forward and inform and advise the review panel, but also the pre-legislative scrutiny work and at other stages too, so that the Bill could be based on real experience, not just on what politicians and, dare I say it, the civil servants thought would be the right thing to do. So I welcome this Bill.
When in October 2017 Sir Simon Wessely was commissioned to undertake the review, there were a number of reasons that led to that. The first was the one that the Minister has already referred to: the Mental Health Act 1983, which was in place for over 30 years, had had some amendments subsequently but was felt to be out of date. Society and clinical treatments had moved on, so there was a need to look at it. But, for me, there was a more fundamental issue, which was the fact that so many people who found themselves in mental health crisis felt that, somehow at those points of crisis, they were people to whom things were done, to whom society did things, rather than people who were able to be part of and involved in that decision-making—they lost their human dignity in the processes that they went through. There were also issues about family members who were concerned that they were not listened to, when they felt that they knew when people were coming to points of crisis, or family members who felt that they were shut out from the discussions about their relative who was potentially at a point of crisis.
20 of 69 shown
I turn to what the Bill seeks to achieve. The Mental Health Act is there to protect people. Its core purpose is, and will remain, to be able to intervene, detain and treat when someone is so unwell that they present a risk to themselves or others. The overall aims of these reforms are to improve the care and treatment of people with severe mental illnesses when detained under the Act, to improve patient outcomes and recovery, and to protect the public, patients and staff. The existing Act confers certain rights on people who are detained, including the right to appeal their detention at a tribunal and a right to an advocate as well as to a medical second opinion in certain circumstances. The Bill seeks to strengthen and expand these rights. It will require the inclusion in the statutory code of practice of the new and revised guiding principles recommended by the independent review, which in turn informs professional practice around the Act. By doing this, we aim to improve things for patients and support a change in culture.
We are strengthening and clarifying the detention criteria to make clear that people will be detained only if they pose a risk of serious harm to themselves and/or others, and if there is a reasonable prospect that they will benefit from the proposed treatment. We are reforming the use of community treatment orders—CTOs—to reflect the revised criteria, to increase oversight and scrutiny of decision-making, and to improve the transfer of patients under a CTO from hospital to community services. We are also introducing statutory care and treatment plans for patients detained under the Act, except when under very short-term sections, to provide a clear plan for a patient’s recovery and a path to discharge.
Where the patient’s voice has previously been unheard, the Bill will place them at the centre of their care and treatment. We are introducing a new clinical checklist requiring clinicians to, as far as possible, involve patients in decisions about their care and to take their feelings and wishes into account.
We are making sure that patients know they can create an advance choice document and that appropriate support is available to help them do so, allowing those at risk of detention under the Act to outline their wishes and decisions while they are well. This document helps them retain control over decisions about their admission, care and treatment if they later become too unwell to communicate these preferences. Last week I saw and heard about the differences that these can make on my visit to the South London and Maudsley, where the words of welcome from service users about these measures highlighted the contribution that advance choice documents can make, particularly to tackle racial inequalities.
We are allowing patients to choose a nominated person to look out for them and their interests when detained and will be increasing their powers. The independent mental health advocacy service was a notable success of the 2007 reforms to the Act. It is a thriving sector, with advocates and volunteers working for excellent organisations such as VoiceAbility, making sure that people are involved with decisions about their care.
We are now looking to expand these services in two ways. First, we are making sure that patients who come into hospital voluntarily can access an advocate to help them understand their rights and be involved in decisions about their care. Secondly, for detained patients, access to advocacy will be on an opt-out basis, ensuring that patients are proactively offered this support when detained to improve advocacy uptake among detained patients.
I know only too well that noble Lords are acutely aware that for some people with a learning disability and autistic people, detention is both non-therapeutic and unnecessarily long. In order to better meet people’s needs in the community, we will limit detention so that people with a learning disability and autistic people can no longer be detained beyond 28 days, unless they have a co-occurring mental health condition that requires hospital treatment. This will affect only civil patients. Hospital will remain an option for those in contact with the criminal justice system, where the only alternative to detention in hospital is prison.
For people with a learning disability and autistic people, the right measures and support are very much needed alongside this change. That is why the Act will require that when people are detained, there is a care (education) and treatment review to be given due weight in decision-making. We are also creating new duties on commissioners to hold registers to help manage the risk of people going into crisis and being detained, and to better meet the needs of people through appropriate community services.
I am grateful for the work of the Ministry of Justice Minister, my noble friend Lord Timpson, and his department, to improve access to mental health care and treatment for people in the criminal justice system. The Bill will end the use of both prison and police cells as places of safety. It will end the use of remand for own protection under the Bail Act where the court’s sole concern is the defendant’s mental health.
We will introduce a statutory 28-day time limit for transfers from prison and other places of detention to hospital when a person requires treatment for their mental health under the Act. We will also introduce a subset of conditional discharge, called supervised discharge, to support the small number of restricted patients who are no longer benefiting from being in hospital.
We are aware that there have been concerns about public safety and are therefore ensuring that our reforms do not weaken the ability to detain people who could pose a risk of serious harm to themselves or others. I assure your Lordships’ House that these reforms do not change the core function of the Mental Health Act. Clinicians will remain able to intervene, to detain, and to treat whenever someone with severe mental illness presents a risk to themselves or others.
We are confident that this is the right package of reforms. However, the Bill further strengthens the measures in respect of public protection. The Bill improves on the previous draft Bill by: first, accepting the Joint Committee’s recommendation to remove “how soon” from the new detention criteria, making sure the Act cannot be misinterpreted to mean that a harm must be imminent to justify detention and early intervention; secondly, introducing a new requirement for the responsible clinician to consult another person when they are making a decision about whether to discharge a patient; and thirdly, strengthening the code of practice’s guidance on discharging patients and promoting the need for discharge planning tailored to the individual needs of patients and their circumstances. We will consult on changes to the code.
I am very grateful to noble Lords across the House for their ongoing support for and interest in the Bill. It has been a long time coming, and I know that we all want to get this on the statute book, which is why it is a priority piece of legislation for this Government. There has been a failure to reform, but today we begin to change that. I look forward to what I know will be a collegiate and constructive debate, which many will follow—inside both Houses and outside. I beg to move.
These issues occupied centre stage in the Wessely review, which proposed the formal recognition of four key principles that should from now on govern both theory and practice in this area of the law. The principles are: choice and autonomy; least restriction on liberty; therapeutic benefit; and the person as an individual. The previous Government fully accepted these four principles and—giving life, as it were, to those principles—the draft Bill set out to make a number of important changes. It strengthened the rights of patients with a learning disability, it gave patients greater autonomy in choosing how they wish to be treated, it introduced duties on commissioners to better understand and support people with a learning disability or autism, who may be at risk of crisis, and it sought to update community treatment orders, which are one of the key drivers of racial disparities in the numbers of people subject to restrictions under the Act.
It is therefore very pleasing indeed to see this Government’s firm commitment to enacting exactly these reforms, and I, for one, hope that as the Bill proceeds, we can come together as a House to implement and, where necessary, improve this hugely beneficial set of changes.
With consensus as the thread that, happily, we expect to run through our consideration of the Bill, there are nevertheless certain themes within it that are likely to require our particular attention. The first of these is community treatment orders. CTOs were first introduced in the Mental Health Act 2007. The Joint Committee on the earlier draft Bill was very clear that CTOs had been widely overused and that they are one of the leading causes of the racial disparities that I referred to a minute ago. The Bill before us makes a number of changes to the criteria governing the use of CTOs, all of them designed to support two of the key principles in the Bill: those of least restriction and therapeutic benefit.
As far as they go, these changes are desirable. However, the Bill stops short of including the full suite of recommendations made by the Wessely review. The Centre for Mental Health has raised this as a key concern. It points out that there is still no persuasive evidence of the benefits of CTOs. Against that background, it argues that a number of checks and balances are needed on the use of CTOs in future, over and above those already in the Bill. In particular, it notes that the committee recommended a full statutory review of the use of CTOs to report within a fixed timeline, which, on the face of it, is the least that we should be doing. I think we will want to debate in Committee why the Government have not felt it appropriate to go as far as the Joint Committee and the independent review recommended in this area.
The next important theme is children and young people. According to NHS data—and this was highlighted by the noble Lord, Lord Darzi, in his recent review—932 children in mental health units were subject to restrictive interventions in 2023-24. In total, more than 84,000 restrictive interventions were carried out on these children, which is a 51% increase from the year before. This is the highest number of restrictive interventions recorded since figures were made available in 2019, and that is despite the number of children in mental health units appearing to decrease.
We have a duty to use the Bill as an opportunity to identify ways of reducing such restrictive interventions and using them more humanely and more proportionately. Two years ago, the Government launched the Oliver McGowan training for NHS staff to help them better deal with young patients with autism. Noble Lords may remember that this was in response to a truly harrowing and appalling set of occurrences that ended with the death of a young man. It is fair to say that the case shook the health service to its core. I believe we have in the Bill the opportunity to take forward those lessons so as to protect children who may be at risk from unwarranted detentions.
The independent review and the Joint Committee had much to say about how treatment of children under the Mental Health Act could be improved. Unfortunately, by no means all those recommendations have found their way into the Bill. One such omission relates to the inappropriate placement of under-18s into adult wards or facilities that can sometimes be miles away from their home. The Joint Committee found that in each of the years 2016-17, 2017-18 and 2018-19, over 1,000 children were placed out of area, and that in 2020, 21% of children and young people were placed as in-patients more than 50 miles from their home.
It is perfectly obvious that being taken to an unfamiliar environment in a place far away from friends and family is almost guaranteed to exacerbate the issues young people face when experiencing a mental health crisis. On top of this, data from the Care Quality Commission showed that in 2021, 249 children and young people admitted for mental health treatments were housed on adult wards for more than 48 hours, some for a good deal longer than that. These are uncomfortable figures; I hope noble Lords on all sides of the House will want to ensure that, through this Bill, we take all possible steps to bear down on the scale of these problems and strengthen the protections afforded to children and young people.
One of the core themes that has remained prominent throughout the process that has led to this Bill is that of choice: giving patients as great a degree of autonomy as possible in how they are treated and maximising their ability to determine what happens to them if they are detained. In that regard, I think the Bill succeeds on many counts, but one measure recommended by the Joint Committee was that there should be a statutory right to an advance care document for every patient who has been or may be detained under the Mental Health Act. The Bill, as it stands, does not follow up on this recommendation. Instead, it places a duty on NHS England and integrated care boards to make information regarding such documents available to patients. I do not doubt that this is a beneficial reform, but we should debate whether it goes quite as far as it usefully might. Guaranteeing patients and service users the chance to state and record their preferences for care and treatment plays directly into the key principles of choice, autonomy and treating every person as a rounded individual—so what are the barriers to doing that?
There are a whole host of detailed issues which we will need to cover in Committee. The final, major area I want to touch on is that of the role played by the police. Inevitably, circumstances arise in which the police are required to become involved with people who may be a risk to themselves or to others. There is a strong feeling that encounters with the police are far too common for people with mental health conditions. As the independent review and the National Police Chiefs’ Council have pointed out, the presence of the police in situations where a mental health issue poses a risk of serious injury or death can be counterproductive. In its written submission to the Joint Committee, the Metropolitan Police stated that:
“Our officers simply cannot provide the specialist care needed, exposing both patients and officers to extreme risks”.
The NPCC has also expressed its concern that the role of the police in mental health pathways must be reduced.
It is welcome that the Bill goes some way to addressing this. Clause 46 removes police stations and prisons as places of safety, thereby preventing patients experiencing mental health crises from being locked up inappropriately. However, there is a potential knock-on effect that we should talk about in Committee. Well-intentioned as the provision is, it could well lead to a rise in people being admitted to accident and emergency departments, escorted by the police, and having to wait in crowded spaces with the lack of the necessary, specialised facilities until they can be assessed by clinicians. In this environment, the risk of harm could well be multiplied. We need to ask how this risk can best be mitigated. I fear that any realistic answer will need to involve resources, by which I mean taking steps to ensure that the requisite arrangements are made for NHS trusts to deal with an increase in the number of mental health patients being admitted to hospitals as places of safety. This is not an easy set of issues, but it is a subject that we cannot duck.
Parliament must see to it that wrongful, inappropriate and untherapeutic detentions of those undergoing a mental health crisis are brought to an end. The Bill provides us with a necessary and welcome opportunity to transform the treatment of those with mental health conditions and to bring both doctrine and practice well and truly into the 21st century. Along with my noble friend Lord Kamall, I look forward to working with the Minister and with noble Lords on all sides of the House to scrutinise and—where we can—improve the Bill’s provisions. Many thousands of the most vulnerable members of our society are depending on us to do so.
Those of us on these Benches will support anything that makes clinicians have to be more accountable and transparent in their work. We can have any legislation we like but, until such time as we call decision-makers to account, we are not going to get anywhere on behalf of people who are detained. They may be detained for their own good. They may be detained for the safety of others, but they are none the less detained. Their opportunities to challenge the decisions made are quite rare. As ever in this House, in the end, when we are coming to a decision, we always have a duty to defend human rights. Human rights legislation exists to defend the people that nobody in society likes. Quite often, that means the people subject to this legislation.
On the issue of principles against the Bill, having gone through the Mental Capacity Act, and having then subsequently reviewed it and its implementation, with serried ranks of professionals coming in to tell us that they just ignored the principles which had been in that Bill since the beginning, I am not overjoyed that they are going to be stuck into a code of conduct. This will surprise the noble Baroness, Lady Merron, not a lot. I do not honestly think it will make any difference at all. They are very good principles but, unless and until they are in the Bill and practitioners believe that their decisions will be judged against them, they will be useless.
Lots of other people can speak about learning disabilities far better than I can. I want to say just two things. First, the noble Earl, Lord Howe, talked about training professionals in relation to young people. Increasingly, people are diagnosed with learning difficulties, and particularly autism, as older adults. We should listen to what the noble Baroness, Lady Hollins, has been telling us for years and require all mental health practitioners to have training in the diagnosis of learning disabilities and autism. That is the one thing that would make a swift and tangible difference in this area.
Secondly, the alignment—or non-alignment—of the Mental Capacity Act and the Mental Health Act has been problematic. We have known about that for more than 20 years. To everybody who knows about it, I simply say “Bournewood gap”. To those who do not, I say that the two pieces of legislation are built on completely different bases. Two people, sitting side by side, can be treated according to one or the other depending on who is in the room at the time. If you get banged up under one, you have quite a lot of rights; if you get banged up under another, you do not. I understand why Sir Simon and his team thought that it would be too long and too difficult a job to sort this out. It was much better that we carried on to do some of the more urgent things in this Bill, but we have to go back and do it. Other jurisdictions are going down that path.
The one thing that the noble Baroness and the Government have to do is give a commitment that they will monitor that and, upon the passage of this Bill, put in place a system of funded research about the change to bring in what is known as fusion legislation. If we do not, we will just consign a load of people to being wrongfully treated, so I hope that she will do that.
In a similar vein, Dr Lucy Series and Luke Clements, who are academics and practitioners who have worked on this for a long time, sent us a briefing that explains in characteristic detail the deficiencies that arise under Section 73 of the Care Act 2014. It means that people who are being treated in private settings, even though their treatment was commissioned by the NHS, are not being properly protected by the Human Rights Act. They have written a very short but effective paper for us, and I simply ask the noble Baroness to commit to a meeting of interested Peers—there are a number of us—with Dr Series and Luke Clements, so that we can deal with that. Can we stop treating people differently just because of the person or organisation that happens to be providing their care?
On CTOs, we are not allowed to wear T-shirts in here but, if we were, I would be sorely tempted to wear one that reads, “Told you so”, because we did. In 2006-07, we sat here night after night saying, “You are telling us that this is not going to be used very often or used disproportionately against some people. That is not true, is it?” It really was not. Because of that and the racial disparities, I and others were for a long time of the view that CTOs really should go because they were enabling bad practice by practitioners. What changed my mind was listening to patients and their families, because there are a small group of people for whom CTOs work, are the least restrictive option and are beneficial. We should therefore keep them. I am reluctant to admit that, but we really have to change all the processes around them to make sure that practitioners are sticking to the intention.
Advance choice documents are another “I told you so”. I am so pleased that they have done what enlightened practitioners said they would back in 2005-06; they have improved care for people. I am indebted to the noble Baroness, Lady Finlay, for telling the joint scrutiny committee about the work that was done in the field of palliative care to make sure that advance choice documents are electronic, and therefore more widely available, and to minimise excuses on the part of practitioners: “Well, I didn’t know about it”. A team from King’s has been looking at that. I hope that, during our discussions, we can go into that in greater depth. I do not quite know how that will work, but it is important.
On prisons and police stations, we were very lucky in the joint scrutiny committee because one of our members was an A&E doctor so we talked about this quite a lot. The truth is that people will still turn up in A&E because the lights are on. That is where people in distress will go. There will also be people who, faced with somebody who is having an episode, still call the police, because they are frightened and do not know what to do. During the passage of the Bill, I hope that the Minister will explain how £26 million will deal with what is quite a big problem and that we look at the transition to the police stepping back to leave everybody else to deal with people who, at the point they meet them, are very ill and disturbed and who need help.
Finally, some of us argued strongly for a mental health commissioner. That was not because we wanted another commissioner—we have lots of commissioners for things already—but because we were trying to deal with a key issue. We do not have a system of mental health care or joined-up services. We have episodes of care, some of which are very good at the time but do not work together as a system. After the hours that we have sat in this place and looked at the various different bits of legislation in great detail, we do not understand why we lock up more people, year on year, and what the best use is of the resources available—they are not infinite—not only to deal with people who are experiencing real crises and trauma but to ensure that we use the best of what we have to put as much as we can into services that are also preventative.
It is a great privilege to be in this House. It is an enormous relief that we can do our work in great detail and largely away from the pressure of headlines, which I know people in the other place always feel whenever there is a failure. It may well be that, during the passage of the Bill, something in the media changes the national mood on this, but our job, privilege and responsibility is to think of the people who are in the worst possible place under this legislation and to do the best possible job that we can for them to make sure that we get the best out of this legislation.
Failing to allow for thorough assessment may worsen mental health care provision and further racial inequalities, as currently Part III detentions disproportionally affect black men.
To combat this, an emphasis on continuity of community care would cut the number of people admitted for an assessment, while ensuring that patients remain safe within the community, yet there is a chronic lack of community-based workers, with a third of all nursing vacancies being in mental health services. I therefore ask the Government to provide clarity on how they will ensure that those who, in the past, would have been detained for assessment and treatment will still be able to obtain a full diagnosis and the support that they deserve, preferably without hospital admission. Careful consideration of workforce planning in the community for social work and allied health professions, as well as psychiatrists, general practitioners and nurses, should form a significant part of the preparation for this Bill’s implementation; then patients and cares could more often be appropriately assessed, treated and cared for by both mental and physical health services, in community and primary care settings, thus avoiding admission.
The Bill offers an opportunity to improve support for those under the age of 18 who are admitted formally under the 1983 Act, yet it is estimated that 31% of under-18s are—thank goodness—admitted informally to hospital for assessment and treatment. I fully support the introduction of new statutory care and treatment plans, but I ask the Minister if they could be extended to those admitted informally, if it is a correct solution.
The Government are right to state that these plans will encourage patients to engage with treatment towards their discharge and beyond. Care and treatment early in a person’s life provides better outcomes than later intervention, so extending these plans to the significant number of informal patients aged under 18 could provide a solid foundation for later life. Additionally, ensuring the availability of quality community services would also reduce childhood detention. I therefore ask the Government to confirm their plans to encourage this early intervention via both the community and the care and treatment plans.
The Bill would be strengthened if it were to improve the environment for young patients. I will not repeat what has been so ably explained by the noble Earl, Lord Howe. However, we really ought to move to a statutory requirement that young people are not allowed to be kept in adult wards for treatment in crisis, or treated miles from home.
There must also be an exploration of the place of parental responsibility before the Bill is finalised. The introduction of a “nominated person” as well as “advance choice documents” are commendable steps to improve agency for those detained under the Mental Health Act. Some young people will choose not to include their parents for either of these. I therefore ask whether the Government can provide clarity as to how this will function with expectations of parental responsibility.
Healthcare professional bodies support the principle of ensuring that prisoners with severe mental health conditions are swiftly transferred to hospital, where they can receive proper treatment, but I have questions of practicality for the Government. What is the plan to ensure capacity in the in-patient sector? What happens to those who clearly cannot be properly treated in the in-patient sector, or who are a significant danger to others on the ward? As a former ward sister, I know that this is a real question from people working in those environments at the moment.
Will there be an assessment at the end of a patient’s treatment to determine whether they are recalled to prison or given a community treatment order if it is safe to do so and better for their mental health? I would welcome working with the Government to get clarity on this issue, particularly in relation to a code of practice.
As I have already said, continuity of care in the community will be essential to prevent unnecessary detention and to provide support to patients after detention. I therefore ask the Government to clarify the implementation timetable for the Bill in order to ensure that current staff have time to receive the development needed and that the necessary new staff are recruited.
I ask too whether there should be a research investigation into safe staffing ratios in the community. The Royal College of Nursing is calling for a maximum caseload for mental health community nurses to ensure that community treatment orders are conducted properly and that nurses can assist in preventing crises, but very little research into this ratio issue has been done outside in-patient facilities. It seems right that research and planning be done to ensure that the community can help fulfil the Bill’s admirable aims. A recent paper by King’s College refers to “frugal innovation” in healthcare. Investing properly in community care will reduce the costs overall.
I trust that the potential shortcomings of the Bill as it stands can be amended and/or resolved through the code of conduct to ensure that it is future-proofed and significantly enhances mental health service provision for patients, which is the aim of His Majesty’s Government, the vast majority of Members of this House and healthcare professionals themselves.
It is also important that, in evaluating the changes to the Act, the Secretary of State has the appropriate data to do so. What steps are the Government are taking in the Bill or in other ways to mandate this kind of data collection, so that racial inequalities are monitored?
The Royal College of Speech and Language Therapists also emphasises that communication considerations are important to the Bill. In my experience, some faith communities find it very hard to discuss mental health, and that is made worse by the biases and discrimination they meet when they seek help. The patient and carer race equality framework is to be welcomed as the first ever anti-racism framework for mental health trusts and service providers. In order to assist in this, the Royal College of Nursing has recommended that mandatory training on equalities be given to all working under the Mental Health Act. As I often say in this place, faith literacy is an essential component of that.
Much of this is still about trust and culturally competent care. It is critical that services be accessible and effective for people with different traditions, cultures and faiths. Empowering patients to offer their data is as important as mandating that it be collected.
Many briefings note that the Bill will be effective in reducing racial discrimination and health inequalities only if there is investment in community services and other actions. Not everything we can and should do is medical; the involvement of the voluntary and community sector is also crucial.
I welcome the provisions in the Bill to restrict the long-term detention of autistic people and those with learning disabilities. I support the Joint Committee on the draft Bill’s recommendation of clearer duties for ICBs and local authorities to develop robust community services and social support.
I pay tribute to the work of the work of the noble Baroness, Lady Hollins, and the independent care and treatment review programme to expose the serious harm and trauma inflicted by the use of solitary confinement, detention and long-term segregation in mental health and specialist learning disability hospitals. I too support the comments made by the noble Earl, Lord Howe, with regard to young people.
The right reverent Prelate the Bishop of Gloucester is the lead Bishop on prisons for the Church of England, and she apologises for not being in her place. She and I commend the Government on bringing forward the long-overdue provisions to end the use of prisons and police cells as places of safety. The right reverend Prelate has told me that last year more than 300 people suffering mental health crises were taken not to a hospital but to a police station. According to the recent report from the Chief Inspector of Prisons, the average time to wait to transfer mentally ill patients from prisons to hospitals is 85 days—almost three months. We welcome the statutory time limit of 28 days, but I highlight, as other noble Lords have, that if this is actually to happen, it needs to be resourced. As the noble Baroness, Lady Watkins, highlighted, there is a question of resource not just on this point but for much of the Bill.
Shortages of mental health nurses and doctors impact on those detained under the Mental Health Act and in the community. The learning disability nursing workforce in the NHS has dropped by 44% since records began in 2009. Investment in the workforce will be key to the success of the Bill. Community services can be developed and resourced only as far as the NHS, local authorities and directors of adult social care are supported to do so. I welcome the Bill and look forward to following its passage and working on what is an extremely important reform.
My noble friend mentioned this in her opening remarks. I stress again that autism is not a mental health condition, but given that eight in 10 autistic people experience mental health issues, without the right safeguards there must be concern that the new provisions could simply lead to a continuation of the current intolerable situation. I hope my noble friend, who kindly met with me recently to discuss these matters, will seek to assuage my fears on that point.
The Government have also said:
“Police and prison cells will also no longer be used to place people experiencing a mental health crisis … Instead, patients will be supported to access a suitable healthcare facility that will better support their needs”.
The right reverend Prelate referred to this in her remarks. The Lampard Inquiry was set up to look at more than 2,000 deaths of people in in-patient mental health facilities, specifically in Essex, and it is believed that many of those who died were autistic. I say to my noble friend that it would be wrong to assume that simply switching the location where autistic people are detained is going to achieve a much better way of protecting them.
The Government have also said the reforms will
“introduce statutory care and treatment plans”.
I share the Cambridge centre’s belief that every autistic person who needs support should have access to a statutory plan to enable them to get the help they need. It should not take an autistic person falling into crisis and being detained in a mental health hospital for such support to be provided, as is often the case today. Autistic people who are at risk of falling into crisis should have a similar right to such plans to prevent in-patient detention becoming a risk in the first place.
A focus on prevention would be in line with Wes Streeting’s idea of reforms of the National Health Service. It is recognised that the current system does, in fact, have a range of provisions, legal rights and safeguards that should, in theory, have reduced the number of people detained in in-patient mental health services. But published statistics show us that this has not happened, with thousands of people still inappropriately detained, so I ask my noble friend to consider these concerns as the Bill passes through the House in Committee and so on.
There is a danger of allowing, even unintentionally, the creation of a critical gap between what happens at a policy and legislative level and what happens on the ground. Without reckoning with this gap and setting up measures to ensure that what is said by government turns into real action on the ground, these reforms will not change the decades-long scandal of thousands of autistic people being detained inappropriately. To do this will require clear measurement, consistent and regular accountability and the necessary funding to enable the National Health Service and other agencies to deliver the hoped-for change that we need from this Bill.
The process of amending the current Act speaks volumes. Would that we could have torn up all the current Acts and started again with a fused approach to treating mental health, but we were persuaded that that would just take too long. It has taken too many years to get this far, and now change is urgent.
I have time to touch upon just a few of the many aspects of the Bill. It is right that the Government have agreed—here I say to the noble Baroness, Lady Barker, that we have good news—to embed in primary legislation what I call the Wessely principles: choice and autonomy, least restriction, therapeutic benefit, and the person as an individual. Each principle should be tested against the implementation of current proposals, future reform and change to ensure that patients as individuals remain the heart of the matter.
Least restraint is a key reason for reform, although in practice it is a difficult balance to strike. As the Wessely inquiry report makes clear, as a society we now benefit from a greater understanding of mental health. However, at the same time society has become much more risk-averse. Much of our debate centred around the need to address all avenues of least restraint, particularly given the current inequalities of outcomes, against the risk of unintended consequences for the protection of society and the therapeutic benefit of the patient.
To apply the principles, we need the data to track every patient and their outcomes. I remain appalled at the lack of information and communication across the NHS, which has a negative impact upon so many lives. Each time a person is moved, they are registered as a new patient. How much does that contribute to flawed data and poor outcomes? I urge the Minister to look at that.
A key missing element is technology, as I have said, and I do not mean some clunky, one-size-fits-all NHS-wide system. In short, we need to swiftly develop a national dataset to allow for real-time monitoring and accountability, evaluating variation and inequalities, understanding medium- and long-term trends and informing future policy decisions.
For choice, dignity and autonomy, we recommended a statutory right for patients who have been detained under the Mental Health Act to request an advance choice document to be drawn up and recorded in a way that is accessible digitally. There is no mention of digital in the Bill. Instead, it introduces duties on integrated care boards, NHS England and local health boards in Wales to make arrangements so that people at risk of detention are informed of their ability to make an ACD, a written statement, and be supported to make one.
Our report referenced the potential for creating ACDs via an app, similar in some ways to one already working for end-of-life palliative care, to support all patients. Simply put, it is a no-brainer and transformative, easily accessed by anyone, either on a mobile phone or even on a patient’s clothes, so that when that person is in crisis there is an instant critical guide to who that person is. That would greatly assist the police, if they are in attendance, and those in A&E. I am hopeful that this approach and other smart, cost-efficient moves will be in the code of practice.
The implementation of reform requires constant oversight. We recommended the appointment of an independent mental health commissioner with overarching responsibility to ensure consistency of delivery of the Government’s priorities for patients across England and Wales. This is not about the Government losing control; on the contrary, it is about an overarching small body with the ability to focus upon consistency across the whole sector, ideally using digitised national data to track and monitor the implementation of the reforms over a period of years, working with the associated NHS bodies to promote better outcomes. I ask the Minister: who else will do that?
Furthermore, we must address unacceptable racial disparities and inequalities, particularly among black men, who, as we have heard from my noble friend Lord Howe, are three and a half times more likely to be detained under the Mental Health Act and seven times more likely to be placed on a CTO. But how is that data collected and verified? Indeed, the facts could be worse. Our report was clear that better outcomes would be achieved and inequalities reduced if each health organisation introduced culturally appropriate advocacy and appointed a responsible person to collect relevant data and publish and oversee policies to address these inequalities. A mental health commissioner could ensure that that was done.
Mental health services currently operate in a static world. What happens when someone has a crisis far away from their local authority? We heard on a visit to SLaM in Lambeth that patients sometimes travel miles to Lambeth when on a downward spiral to receive, in their view, better treatment there than within their local authority. That is another reason to have accurate data.
Another critical area is children and young people. Issues highlighted in our report, including the role and profile of nominated persons, detention in adult wards and conflict with the Children Act, must be clarified and assurances given to families and their young. Investing in and building the right community support and action plan for people with learning disabilities and autism no longer detained under Section 3 is critical, as is monitoring the outcomes for those with learning disabilities and autism who may be at risk of being detained under the Mental Capacity Act or through the criminal justice system instead. This is an area where our committee had a strong debate, concerned about unintended consequences that might impact on the patient and/or society at large if the right protections, including safe spaces, were not in place. Are the Government content that they have achieved the right balance?
I feel I must record—because I want to be helpful to the Government—that our committee had one opportunity to put some of the crucial questions to, and test the opinions of, around 18 officials from the DHSC and the MoJ who had worked on the Bill for four years. That meeting was cut very short because one official said she had to collect her child from school, so all 18 walked out. That must not be allowed to happen again.
Priorities must be set for the implementation of the many proposals, and there needs to be a significant increase in capacity right across mental health services, all of which requires enormous investment. I wish the Government, particularly the noble Baroness, Lady Merron, well.
I would have liked to see a Bill that addressed all mental health and capacity issues, putting capacity for decision-making at its heart, consistent with the United Nations Convention on the Rights of Persons with Disabilities, which we currently contravene and have done since its implementation by the UN in 2008. The human rights implications of the current Bill are profound. It does not address the fundamental rights of thousands of mentally ill people, primarily because of the absence of having decision-making capacity at its heart. We accept that patients with physical disorders can make decisions that may be seriously detrimental to their health or safety. In contrast to this, in mental health law capacity plays little or no role in decisions to initiate psychiatric treatment against a patient’s wishes. The criteria for the involuntary treatment of mental disorders fails to respect the autonomy of the patients. The key considerations are the presence of a mental disorder and risks to the patient’s health or safety. For persons with physical disorders, their personal values are given dominion. Those with mental disorders are not accorded this privilege in this Bill, even though we make such a meal of it in the Mental Capacity Act 2005. There is an underlying assumption that mental disorder necessarily entails an inability to make sound or rational judgments, but even among the most ill patients—those admitted to acute psychiatric wards—40% to 60% retain capacity.
People with mental disorders are unusual in being liable to detention, usually in hospital, because they are assessed as presenting a risk of harm to others before they have actually committed an offence. This constitutes a form of preventive detention that is selective. We spent some time in this Chamber a couple of weeks ago debating indeterminate sentences for people in prison thought to pose a continuing risk in the community. There was widespread agreement here that it was an iniquitous thing. And yet mental health law allows the detention of those with mental disorder on the basis of risk alone. How can that be justified? There is no evidence that risk is easier to assess in those with mental disorder or that violence is more predictable in this group, and it is an expression of the prejudicial stereotype that people with mental disorder are intrinsically dangerous, contrary to research evidence.
This does not mean that people’s dangerousness is unimportant. If it is reliably linked to an individual’s mental disorder, then, if the person lacks capacity, involuntary treatment may be justified, but if the patient has capacity, protection of the public becomes the sole interest. I do not deny there are problems with a capacity-based regime. Many people think you have to fudge the decision, but I would say it was because they do not understand the fundamental ways to assess capacity and the full influences on it.
One of the aims of this Bill is to reduce sections. The number of new sections, as we know, has rocketed again. Last year, there were over 52,000 sections, a further 5,000 or so placed on a community treatment order, and 140,00 people on mental capacity deprivation of liberty safeguards. If the aim of the new Act is to reduce detentions, I cannot see how. The discharge rate from tribunals has reduced from 25% in the mid-1980s to about 6% today. How is it going to happen exactly under this legislation?
I do not see how the overrepresentation of black people in the detained population is to be addressed by this Bill. We need a completely different new way of assessing people and allowing people to get access to services that are sensitive to their needs, providing something that they want to access. I cannot think that there is anything new in this Bill which reflects new thinking that is going on about how you encourage people to access services when they first begin to feel ill.
The Bill has nothing to say about restraint and seclusion. It does not address the hundreds of people in the prison system and their non-consensual treatment except to speed up those that are suitable for transfer. The majority of the mentally unwell will never even be considered for transfer, but they have terrible problems which impact on the prison system tremendously.
Finally, it is now 14 years since the Mental Health Act Commission was abolished and replaced first with the mental health commissioner and now by the totally inadequate low-profile CQC, which has no legally qualified members and no mental health representation at executive board level. Whereas the former chair and vice-chair of the commission had direct access to the Secretary of State for Health, as I am sure the noble Baroness, Lady Bottomley, will remember—she got tired of seeing us, I should think—mental health does not now appear to have the same direct influence. Perhaps it is not surprising that mental health appears only on the government agenda when there is some crisis that has been brewing for years or, as now, after meandering for years through our scrutiny and committee systems.
I have had my say. I am not going to raise this issue again. I felt I had to say it once. I will throw myself into Committee with enthusiasm and hope we can get this Bill through, but I do hope that one day we will get the mental health and capacity legislation that we really need.
Then there was the overuse of detention. Reference has already been made, and I am sure will be made by others in this debate, to the racial disparity in the use of detention, a matter which should concern us all. There was also the question of the use of detention for those with autism and learning disabilities. All those issues underpinned the reason for looking at reviewing the Mental Health Act 1983.
The first point has been that issue about the loss of dignity and the way in which people in mental health crisis are treated. I hope that will be dealt with by those very first principles that appear in Clause 1. I draw particular attention to the fourth of those:
“The person as an individual”.
Under “Matters to be addressed”, it says:
“treating patients with dignity and respect and considering their attributes and past experiences”,
although I accept, as the noble Baroness, Lady Murphy, just said, that it is not enough simply to put it on a page of legislation. For that to be enacted requires changes of culture and attitude from all those who deal with people in mental health crisis.
Part of this sense, though, of people being able to feel that they are making decisions for themselves is the advance choice document enshrined in this legislation. I am sure that the Government will want to think carefully about the matters that it might encompass, and about its interaction with potential future legislation.
I want to pick up the issue of the nominated person. I mentioned families feeling that they are sometimes cut out but of course, as we know, sometimes for the individual with mental illness or mental health problems the nearest relative—that family member—might not be the most appropriate person to be their nominated individual. That individual may actually be somebody with whom—how can I put it?—the tensions can lead to increased difficulties for the person with mental illness, rather than reducing them. That ability to nominate somebody else as the person who someone wants to be there is critical. The noble Baroness, Lady Watkins, referred to this in relation to children but I think that, in general, it could create some tensions with family members who feel that it is their right to be that person alongside the individual in mental health crisis. Having said that, I believe that the nominated person point in the Bill is absolutely appropriate.
I want to focus also on the questions of detention. I have referenced how we need to look carefully at the inappropriate racial disparity in detention, but I also want to comment particularly on the police issue. I am pleased to see the outlawing in the Bill of the use of police cells and prisons as first places of safety. This is of course the culmination of work in progress. There was voluntary work with the police and the health service, in 2012 and subsequently, to encourage and help them to ensure that the first person who someone in mental health crisis saw was not a police officer, and that they were not taken to a police cell as a place of safety. We then ensured that work in the Policing and Crime Act 2017, so that police cells could not be used as places of safety for those under the age of 18. The Bill takes it that bit further and it is absolutely right that it does—and right to do it for the individual who is in mental health crisis.
It is also right to do that for the police, because one issue that police officers themselves constantly made reference to me about was their fear and concern about being expected to deal with somebody who was in mental health crisis, when they had no training and no capability of knowing what to do in those circumstances. Of course, it is bad for the individual too if they are faced with somebody who has no actual understanding of what their condition is or how they should be dealt with.
Perhaps I may gently say to the Minister that in 2015 we put £15 million into providing alternative places of safety and in 2017 the Government put £30 million into providing them. This Government are now putting £26 million into providing those alternative places of safety. It is easier to say this from this side of the House, but the Government might wish to consider those figures, if I can put it like that. I also suggest to the Government that they consider alternative places of safety as not necessarily being a healthcare facility. Many places in the third sector are able to provide those facilities and the Government should look at that as well.
Finally, we also need those facilities to try to ensure that people are less likely to get to the point of crisis. If they are less likely to get to that point, they are also less likely to turn up at A&E because they are in crisis. That would be a win-win for the individual concerned, for the Government and for the health service.
Overall, I welcome the Bill. There are some very good provisions in it. As we have heard, it will be subject to detailed scrutiny in this House but it is no bad thing—I can say this now—that it started in this House. I welcome it and look forward to its passage.