Baroness Tyler of Enfield:

Moved by Baroness Tyler of Enfield

50: After Clause 51, insert the following new Clause—“Workforce sufficiency assessment by Integrated Care BoardsAfter section 142C of the Mental Health Act 1983 (inserted by section 51 of this Act), insert—“142D Workforce sufficiency assessment by Integrated Care Boards(1) Each Integrated Care Board must conduct a workforce sufficiency assessment every two years to evaluate whether it has sufficient workforce resources to deliver services under this Act effectively. (2) The assessment may include—(a) an analysis of current workforce levels across all relevant service areas;(b) identification of workforce shortfalls;(c) an evaluation of the impact of staff shortages on patient care and service delivery;(d) proposals to address workforce challenges.(3) Integrated Care Boards may consult any relevant personnel or organisations they deem appropriate when conducting the assessment.(4) Each Integrated Care Board must publish a report outlining its findings upon completing the assessment.(5) The first reports must be published 12 months after the day on which the Mental Health Act 2025 is passed.””Member’s explanatory statementThe amendment requires Integrated Care Boards to produce a biennial report assessing workforce sufficiency, identifying shortages, and proposing measures to address workforce challenges in delivering services.

It is funny how these amendment groupings work, is it not? I will speak to my Amendment 50 and say a few comments on Amendment 59 in the name of the noble Lord, Lord Stevens, to which my name is attached.

We have talked a lot throughout the passage of this Bill, and rightly so, about the importance of how it is implemented and in particular about ensuring that sufficient resources are available to allow a much-needed expansion of community mental health services. To be blunt, unless this happens, the Bill just will not be implemented. To put this into context, those waiting the longest for elective community mental health care—both adults and children—have waited two years, which is twice as long as those waiting for elective physical health care. Parity is still a long way off.

I was very grateful to the Minister for sharing the Government’s implementation plan and for arranging a helpful discussion with her and officials.

My Amendment 50 would require integrated care boards to produce a biennial report assessing workforce sufficiency, identifying shortages and producing measures to address workforce challenges in delivering these services. We all understand that it will take time to enact the Bill’s provisions and that systems will take time to build capacity, including training of an expanded work- force—particularly given existing workforce challenges. In Committee, I talked about the workforce impacts of the Bill, drawing on figures and research from the Royal College of Psychiatrists. I will not repeat those figures, save to say that NHS England set a target back in 2016 to have more than 1,040 consultant psychiatrists in post in England by last year. Based on these targets, as of last year, there was still a shortfall of 769, so we still have a long way to go. Of course, the mental health workforce goes considerably wider than consultants.

I turn to Amendment 59 in the name of the noble Lord, Lord Stevens, to which I have added my name and which we very strongly support on these Benches. This amendment would ensure that mental health funding is not cut as a share of overall health service funding until this Bill is fully implemented. Indeed, it is vital, given the pressures on public finances, including on the overall health system and the pressures that they pose to mental health spending. Critically, the amendment would not tie the Government’s hands in whatever decisions they make about the overall level of NHS spending.

One reason why I support this so strongly is because the Written Statement from the Secretary of State on 27 March on the amount and share of spend on mental health was, frankly, not reassuring, with mental health spending expected to go down as a proportion of overall NHS spend this year and a forecast for similar next year. I know that it was small amounts, but this could be part of a trend. It just reinforces the point that mental health spending and parity of esteem are not currently sufficiently protected, which I believe underlines the need for legislative cover. Therefore, if the noble Lord, Lord Stevens, is minded to test the opinion of the House, we will certainly support him.

I conclude by emphasising that legislative backstops and reporting duties are necessary to ensure that the implementation of the Bill is timely and effective. That is underlined particularly by the delays in the implementation of both the Mental Health Units (Use of Force) Act 2018 and the liberty protection safeguards introduced in the Mental Capacity (Amendment) Act 2019, to replace the deprivation of liberty safeguard systems, neither of which have been taken forward. Both are very relevant to patients affected by the Mental Health Act. I beg to move.

My Lords, this Bill has been years in gestation, and we have heard, in Committee and on Report, that it is going to be years in implementation. The Government, not unreasonably, have pointed to two principal rate limiters for that: workforce and funding. As we have just heard in the powerful speech from the noble Baroness, Lady Tyler of Enfield, her Amendment 50 is responsive to the staffing constraints and concerns, and my Amendment 59 tackles the funding question. I am grateful for her support and that of the noble Baroness, Lady Bennett of Manor Castle, and the noble Lord, Lord Scriven.

In a nutshell, as the noble Baroness says, this amendment does not seek to tell the Government, or indeed the House of Commons under its privilege, how much to spend on the NHS. All it says is that there should be a floor on the share of that total going to mental health for a time-limited period while the Act is being implemented; in other words, the Government would continue to decide the size of the NHS pie. The Government, of whichever complexion, could decide to grow or shrink it, but the slice of that pie devoted to mental health would be protected for a time-limited period, not only at the local ICB level but nationally.

We had a debate on this in some detail in Committee, so I will not repeat the arguments in favour, but I will update the House on two developments since then. First, in consultation with the Public Bill Office, this Report amendment is more tightly drawn, focusing specifically on the mental health services that are in scope of this Bill and are required for its implementation. Secondly, as the noble Baroness, Lady Tyler, has just noted, since we debated this point in Committee, new evidence has emerged, sadly, as to precisely why this amendment is needed. Previously, Ministers have argued, in good faith, that the Government are committed to protecting the mental health share anyway, whereas last Thursday, the Written Ministerial Statement disclosed that the Government now intend to shrink the share of NHS funding on mental health services in the year ahead.

The Written Ministerial Statement says:

“This is because of significant investment in other areas of healthcare”.

That is not a justification; it is a mathematical tautology. It reveals a preference entirely antithetical to what will be required over the years to get this Bill implemented.

It may be argued that it is a small percentage reduction, even though it is an important negative new precedent that has been set. However, a small percentage reduction on a large pound note number itself constitutes a large pound note number. Mental health services will be missing out on hundreds of millions of pounds more, not only in the year ahead but over the decade that it will take to implement the Bill. If that is not corrected in subsequent years, over £1 billion of funding has, in effect, been removed from mental health services and the implementation of the Bill as a consequence of that decision.

In summary, there are, sadly, real grounds for concern about whether the implementation of this Act will be properly and expeditiously resourced. If the Government want to argue that this amendment is unnecessary, because they are going to do what it says anyway, it is not clear why they would therefore object to its inclusion in the Bill. But if the Government’s argument is that they do not support the amendment because they would like the flexibility to cut mental health funding shares, then, to my mind, that really points to the necessity of the amendment.

I rise briefly, having attached my name to Amendment 59 in the name of the noble Lord, Lord Stevens, and backed by the noble Baroness, Lady Tyler, and the noble Lord, Lord Scriven. We saw in Committee multiple amendments all trying to address the resource issue. We have focused on this one because it is both an elegant solution, as the noble Lord, Lord Stevens, just outlined, and it is—emanating from the Cross Benches—a moderate solution that can and I think will attract wide support from around the House.

As the noble Lord and the noble Baroness have said, parity of esteem has never been achieved and, on the current figures, is currently going backwards, in the wrong direction. We have to focus on the fact that the waiting lists for community mental health care for adults and young people and children are twice as long as those for physical healthcare. That is the outcome of the inequality of esteem with which mental health is being treated. I note that the Rethink Mental Illness Right Treatment, Right Time report found that most people living with a severe mental illness experienced worsening mental health while waiting for treatment, with 42% requiring urgent care and 26% being hospitalised. We are aiming to shift from hospital care—in-patient care—to community care, but we are actually forcing things in the other direction because people reach such a state of crisis. I have to preface the horror of what I am about to say with a warning. The Right Treatment, Right Time report found that 25% of people whose mental health deteriorated while waiting for treatment attempted suicide, which highlights how the lack of funding for mental health care impacts on that awful statistic.

This is a step to create a framework that heads in the right direction. As noble Lord, Lord Stevens, said, how could you possibly oppose this?

My Lords, very briefly, I will say that I absolutely support this amendment. I think it is worth clarifying what I said earlier about overdiagnosis. The danger is that that can be interpreted as meaning that I want cuts; what I actually want is targeted intervention for the right people, rather than saying, “Oh, everybody’s been calling themselves mentally ill, so let’s cut the services”.

I completely agree with the noble Baroness, Lady Tyler of Enfield, that, if we do not sort out the amount of community provision, what we have done over the last few weeks, never mind the years preceding it, will have been a waste of our time, because the Bill will not be worth the paper it is written on—that is the danger. It is very tempting, in a period of intense economic difficulties, to suggest that this might be one of the first things to go—so I do think this is a very good amendment.

I will remind the House of a discussion we had late the other evening on the plight of prisoners. If there is no community resource for people leaving prison—ex-prisoners—they will deteriorate and end up becoming very ill in the community and being incarcerated again. I discussed that in great detail. In other words, this is essential if we are serious about saying that we do not want to lock people up but, instead, want to treat them appropriately.

My Lords, I rise very quickly to support the amendment from the noble Lord, Lord Stevens, and have put my name to it.

I will add a couple of extra things to the noble Lord’s very well-argued case. Modest as it may be, I think it is an effective measure—and this is why I think it is and why the House should support the noble Lord’s amendment if he decides to push it to a vote. It is not that the Secretary of State has announced that the percentage will decrease next year; the percentage decrease happened during this financial year, going down from 9% to 8.78%. So we are now on a trend for the percentage of National Health Service spend on mental health.

Furthermore, one has to question the priority of the Government when they look at the national planning guidance and some of the targets that have been dropped from it. There are no plans to target the 2 million long waiters waiting for mental health care. It would be slightly disingenuous of the Minister, in response, to talk just about the mental health investment scheme, because all it refers to is ICB spend. The uniqueness and cleverness of the amendment from the noble Lord, Lord Stevens, is that it talks about all health service spend, including non-ICB spend, specialised commissioning and other elements that need to be there.

Mental health takes up 20% of illness treated by the NHS, which will probably be spending 8.7%. Because of the trend that is happening, the amendment from the noble Lord, Lord Stevens, is absolutely vital to ensure not just that the percentage is maintained but that the community facilities within this will be funded and implemented.

My Lords, I will not speak at length, but I express my support for the case put forward by the noble Baroness, Lady Tyler, in her Amendment 50. Her concerns around the resourcing of the mental health workforce are well founded and there is no better source of evidence for those concerns than the CQC, which I thank for briefing me, very fully, on this subject at the beginning of last month.

When we look at the issue of workforce sufficiency, a paradox confronts us. Between 2019 and 2024, the mental health workforce grew by nearly 40,000 full-time equivalent staff—an increase of 35%. Yet, when we sit down to read the CQC’s recently published Monitoring the Mental Health Act in 2023/24, we find that staff shortages are a pervasive feature throughout the service. There is a cocktail of reasons for this apparent contradiction: very steeply rising patient demand; patients being admitted to hospital with a greater acuity of mental illness; a struggle in many places to recruit staff with the right skills; and poor retention of skilled staff, with, as a consequence, a high reliance on agency workers. That all impacts the quality of care given to patients, because, with hospital staff suffering burnout and temporary staff coming and going, there is often no opportunity to develop the kinds of therapeutic relationships that make patients feel psychologically safe and secure.

Of course, not all areas of the country are the same. Geographical disparities affect the availability of different skill sets, resulting in different kinds of problems manifesting themselves: for example, in one of the three high secure hospitals, the CQC encountered cases where patients were being kept in their rooms during the day. Elsewhere, on a number of in-patient wards, patients with autism or a learning disability reported that staff lacked the necessary training to look after them properly. In other settings, the lack of training is more basic: agency staff very often do not know how to operate the hospital’s IT system. This mixed picture underlines the fact that the amendment from the noble Baroness, Lady Tyler, is expressed in exactly the right way, since it mandates that biennial staff sufficiency reviews should be done not centrally but by commissioners locally.

That formula is appropriate for another reason. Depending on where you are in the country, there can be different sorts of barriers to accessing care, whether the barriers are for people from ethnic minority groups, for children and young people or simply for people living in areas of high deprivation. The more people find it difficult to access the care that they need, the more seriously they can be at risk. That particularly applies to children. The noble Baroness, Lady Bennett, made that point. We have not heard much from the Government about workforce planning generally, but this is an area where this exercise just cannot wait.

This leads me to Amendment 59, in the name of the noble Lord, Lord Stevens. It will not be much comfort to him if I say that I am right behind the sentiment of the amendment. He knows that, sadly, I cannot ask my colleagues on these Benches to vote for it, simply because I do not think it is appropriate for primary legislation to tie the hands of Government in matters of health spending. Those macro decisions surely have to be for Ministers.

Nevertheless, the flagship principle at the centre of the amendment is parity of esteem—a principle that is enshrined in statute and to which I am totally signed up, alongside, I am sure, all of your Lordships. However, parity of esteem is a broad concept and should, in my view, be measured in a range of ways, not simply by reference to monetary input, important as that is—and it is important.

The noble Lord is right to focus our minds on the recently published and very troubling announcement on mental health spending. I therefore hope that the Minister will be able to deliver, at the Dispatch Box, some robust assurances on mental health spending, as well as on parity of esteem more generally, which will obviate the need for the noble Lord to press his amendment and will satisfy honour on all sides.

My Lords, I am grateful for all the contributions and considerations this evening, to which I have listened closely.

I first turn to Amendment 50 in the name of the noble Baroness, Lady Tyler. Workforce is absolutely a critical factor in enabling these reforms and we have committed to recruiting 8,500 more mental health staff over the course of this Parliament. The impact assessment sets out our expectations for the additional workforce that is required to deliver the Bill.

However, there are already various mechanisms in place to monitor and address concerns about the mental health workforce. The amendment would be duplicative and unnecessary. Providers registered with the CQC—both NHS and independent services—are required to deploy enough suitably qualified, competent and experienced staff, as outlined in Regulation 18 of the Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. If CQC finds a breach in Regulation 18, it can take action.

The Mental Health Act Code of Practice also states that local authorities should ensure that there are sufficient approved mental health professionals and independent mental health advocates. All staff in CQC-registered providers must receive the appropriate training that is necessary to enable them to carry out their duties under Regulation 18 of the Health and Social Care Act Regulations 2014.

At a national level, CQC reports on workforce sufficiency as part of its monitoring of the Mental Health Act report. We would argue that this is a much better process than requiring integrated care boards to mark themselves on how well they are fulfilling their duties.

Furthermore, as I said on Monday and wish to reiterate, we are committed to laying an annual report on implementation, which will set out progress made and future plans for implementation. This will include information on the expansion of the workforce, including second opinion appointed doctors, Section 12 doctors and approved clinicians. It will also include details of the key statistics and outcomes under the Mental Health Act, including detention rates, community treatment order rates and other key metrics, such as racial disparities and outcomes for children and young people, all of which noble Lords rightly seek. I hope this annual commitment will be welcomed by your Lordships’ House and that this, combined with the existing workforce monitoring I have referred to, will allow the noble Baroness to withdraw her amendment.

On Amendment 59, I also understand —as does the noble Earl, Lord Howe—the intention of the noble Lord, Lord Stevens, which is to ensure that we invest in delivering these reforms. I want to be clear: as I said in Committee, there are already mechanisms in the NHS Act to prioritise mental health spend to deliver these reforms.

To reiterate the point that I made previously, we believe that this amendment is not the right mechanism to ensure that we do that. I will return to the three main reasons for that, but I want first to refer to the point the noble Lord, Lord Stevens, made when he spoke of “shrinking mental health spend”.

It was the shrinking share of mental health spend.

I thank the noble Lord for that correction from a sedentary position. Perhaps I could provide some more clarity, which the noble Earl, Lord Howe, also asked for.

The proportion of spend is almost exactly the same as it was last year, with a difference of just 0.07%. We understand concerns that the share of overall NHS funding for mental health will reduce slightly. However, this does not mean that mental health funding is being cut, and I would not want noble Lords to think that to be the case. To be clear, spending on mental health support will increase relative to 2024-25 and is forecast to amount to £15.6 billion—an increase of £680 million in cash terms, and equivalent to £320 million in real terms.

Perhaps it would be helpful for me to return to the three main reasons for not supporting this amendment. The first is—as the noble Earl, Lord Howe, helpfully referred to—what I would call a point of principle. Primary legislation should not be used to constrain spending in this way. Multiyear budgets for government departments will be set by the established spending review process, which considers spending in the round and in the context of the Government’s policy priorities. Additionally, it is Parliament that is responsible for scrutinising government spending and approving spending set by departments for the current financial year as part of the estimates process.

Secondly, the amendment as drafted applies only to spend under the Mental Health Act. The mental health system, as noble Lords will appreciate, does not structure its accounts based on the legal framework under which a patient is held. A single ward, for example, could contain a mix of patients under the Mental Health Act and informal patients who would not usually be considered to be under the Mental Health Act. Likewise, community services will support a mix of people, some on community treatment orders and others who are not. It would be impractical to require services to split costs based on the ever-changing patient mix within their care.

The third reason for not accepting this amendment, and perhaps the most fundamental point, is that the share of spend on the Mental Health Act could reduce over time, which is not undesirable. I will explain why. The genesis of these reforms is the review initiated by the noble Baroness, Lady May, to address the rising rates of detention. We all want to see more people cared for effectively in the community so that the need for the use of the Act is reduced. This would require more investment in preventive community services, which, I put to noble Lords, is surely the preferable model for supporting severe mental illness. In creating a legal requirement for the share of spend specifically under the Mental Health Act not to decrease, this amendment would actually preclude the shift from detention to prevention that I know we all want to see.

So, while I absolutely understand the intention, and I can commit that we will invest to deliver these reforms, we cannot support this amendment, which, for the reasons I have outlined, we believe is fundamentally flawed. For these reasons, I hope that the noble Baroness will withdraw her amendment and the noble Lord will not press his.

My Lords, this has been another incredibly important group of amendments. We are very short of time. I thank everyone who has contributed. I welcome that the Minister has committed to an annual report on implementation. I hope that there will be an opportunity for a debate in both Houses when that annual report is received. I was very grateful to the noble Earl, Lord Howe, for his support on my Amendment 50, which I will not be pushing to a vote. I do not consider it to be duplicative and unnecessary. If I did, I would not have tabled it. I thought that it was quite good, but I am not pushing it to a vote.

My final comment is that I was very pleased that there was widespread support for the very important amendment tabled by the noble Lord, Lord Stevens. It was variously described as modest, elegant, clever and other things. It had an awful lot going for it, but I leave it to the noble Lord, Lord Stevens, to say how he wishes to proceed. I beg leave to withdraw my amendment.

Amendment 50 withdrawn.