I beg to move,
That this House
has considered reform of the Mental Health Act 1983.
It is an absolute pleasure to serve under you in the Chair, Ms Buck. I thank everyone who has come along to speak on our last day here before the summer recess and in 38° heat—we are used to 38 Degrees in our inboxes, but not in the Chamber. I also thank all the organisations that have supported this debate. In particular, I owe deep thanks to Louise and the whole team at Rethink Mental Illness for supporting me in preparing for the debate, but a huge range of organisations work on this issue day in, day out, in many cases supporting people in very difficult circumstances. They include Agenda, the Mental Health Network, the Royal College of Psychiatrists, Young Minds, SANE, the Mental Health Foundation, VoiceAbility, the Centre for Mental Health, the Association of Mental Health Providers, Mind, and Southwark Carers, which is represented here today. I thank you for everything that you do, on a daily basis, to support reform of the Mental Health Act 1983 overall and for what you have done to support this debate specifically. I also thank the individuals with direct experience and their families, friends, carers, supporters and loved ones. Their personal testimony and experience are what is driving the need for change.
The current Mental Health Act came into force in September 1983. Margaret Thatcher was still Prime Minister—what she would make of the current one I do not know, but that is a different issue. Labour had lost the general election that year with the “longest suicide note” in British political history—but luckily we have learned the lessons of the past. The iron curtain was still drawn. It was the year that Kim Jong-un was born. It was the year that my predecessor in Bermondsey and Old Southwark, Sir Simon Hughes, was getting started on a 32-year stay, until I won the seat back for my party in 2015. I note that the biggest selling single in 1983 in the UK was Culture Club’s “Karma Chameleon”.
For anyone unfamiliar with it, the Mental Health Act is the law in England and Wales that allows someone to be detained and treated for a mental illness without their consent. That is commonly known as sectioning, but for the purposes of today’s debate, I will refer to it as detention. The Act is designed to prevent people experiencing mental health crises from harming themselves or other people, and the Act can be the mechanism that prevents someone from taking their own life. It is hugely valuable when it works. I am sure that everyone here would agree that society and the state should protect the most vulnerable when they are unwell. But the current legislation is decades out of date.
The legislation came into force when I was just four years old, and I had already realised by that point that my life was very different from that of other children. My parents had four children together between 1976 and 1980, but mum then developed schizophrenia—a mental illness that causes muddled thinking or delusional thoughts, and changes in behaviour. The causes of schizophrenia are still very much unknown, but even less was known about the condition in the early ’80s and treatment was rudimentary to say the least. But because of mum’s condition, talking about mental illness has been part of my life for as long as I can remember. That has been the case throughout my family because of our circumstances. It has shaped my life.
Some of my earliest memories are not necessarily the easiest to talk about, but this is one of the earliest memories I have. After mum’s mental health broke down, my parents split up. We stayed with mum initially. She was unable to care for us properly. With the best of intentions, on a cold day when she could not work the heating, she lit a fire in our living room. That fire caused huge damage. The scars from the fire stayed with us literally—physically—because we could not afford to make the necessary changes for some time after that.
Mum kept me out of school, convinced that I was ill; there was no illness. For many years, I was convinced that I had been kept in an incubator after being born, because mum convinced me that I had had lung problems at birth. I found out later that that was not true.
Dad eventually got custody, and the four of us grew up with dad, but on visits to mum, she would be unsupported and unwell. I remember staying over and her giving me a bowl of cereal with what I thought was orange juice on it—the milk was so off that it was orange. But mum had thought that that was sensible; she was just trying to feed us. She did not know, because she was so unwell.
Mum had another son; I have a half-brother called Sebastian. She was unable to look after him because she did not have support. He was initially fostered, but mum’s behaviour became too problematic. I went to see her once and the front door had been broken in. She told me that there had been a burglary, but nothing was missing, and it turned out that the police had had to be called because she had taken Sebastian from the foster carers and they had had to break in to take him back. He was formally adopted at five years old, and I have not seen him since.
It may sound strange or scary to some, but this was my normal; this was my childhood. We are all socialised by our surroundings and families, and the personal situation for me and for many others who grew up in difficult circumstances helps to develop resilience, I think. It has also given me greater empathy, both as a child and now, particularly when I see constituents who are struggling with similar mental health circumstances of their own. I represent a constituency that has a higher prevalence of mental health conditions and psychoses.
I commend my hon. Friend not only on the speech that he is making, but on the very moving way, if I may say so, in which he just spoke about his personal experience and how it informs his views today. Like him, I have had constituents who are dealing with these issues; and like him, I think that we have come to the point at which the Mental Health Act does need to be reviewed, particularly because of—this is the point that he has been making—the impact it has on the immediate family. How can we go forward such that the wishes of the person who is being detained are taken into account and the family’s wishes are taken into account, in a way that provides protection for the vulnerable but also recognises people’s particular needs and choices?
That is very much what I will be coming on to and what I hope we will hear more from the Minister on; it was the subject of an independent review.
I was talking about the prevalence of mental health conditions in Southwark and people I have seen at constituency surgeries. These statistics for Southwark are from the South London and Maudsley NHS Foundation Trust, which is my local mental health trust. Close to 4,000 people have what it defines as a serious mental illness; that does not include things such as dementia. Almost 48,000 people are currently experiencing a common mental health condition. Across the borough, 22,000 people have both a mental health condition and a long-term physical condition. And almost 4,000 children in Southwark have a mental health condition.
I thank my hon. Friend for making a speech that is very powerful and very personal. The number of mental health nurses in England has fallen by 6,000 in the past 10 years. Does he agree that we need the correct number of staff, and staff with the correct expertise, to meet the needs of the service in supporting people with mental health issues?
I absolutely agree and will come on to some of those figures.
I referred to the children in Southwark who have mental health conditions. The NHS’s overall target for ensuring that children and adolescents can access mental health treatment is just 35%. That is remarkably low, and I hope the Minister will have something to say about it today. In the meantime, while that is the national standard, Southwark’s Labour council has set an ambition to ensure that 100% of children and adolescents can have access to mental health care. As part of that commitment, the council has made £2 million available for local schools to support the emotional wellbeing and mental health of pupils. It is also developing a mental health hub service for young people. That is in partnership with—jointly funded by—the local clinical commissioning group.
As I have said, I think that my personal experience has given me an additional strength in working with local people and families who are affected by these issues, but being open about my family experience does not mean that I have not seen discrimination or stigma at first hand. I was about 10 or 11 when I said to a friend at school that Mum had schizophrenia and he asked whether that meant I had two mums. That was a surprising reply, but obviously there was a lot of confusion then about what schizophrenia actually was. Some of it is still out there.
Sadly, one thing that remains is the perception that people with schizophrenia are somehow more dangerous. Actually, mum’s experience and that of many people with schizophrenia is that they are more likely to be targeted, because their erratic behaviour when they are unwell can draw the attention of others, who might target them for robbery and other offences.
I thank my hon. Friend for the way in which he is opening the debate and particularly for his comments on schizophrenia. If they have the right support, there is no reason why anyone with schizophrenia should not live a normal life, including being able to work.
I completely agree. Sadly, the figure for people with schizophrenia in work remains at about 5%. It is just 5%, because the support simply is not there and the medication and treatment are not there on a routine basis to ensure that they are able to work.
Figures suggest that one in four of us will experience mental ill health at some point in life, often because of bereavement or a relationship breakdown. I pay tribute to all the organisations involved in the Time To Change campaign, which has done brilliant work to challenge the stigma and discrimination that affects people with mental health conditions in employment and elsewhere.
The change in language and awareness of conditions is one reason to seek reform now. For example, the Mental Health Act 1983 is defined as:
“An Act to consolidate the law relating to mentally disordered persons.”
The language around mental health has changed much since the current law was enacted. We also need to consider its far reaching powers.
The independent review of the Mental Health Act, published seven months ago concluded:
“The Mental Health Act gives the state what are amongst the most significant powers that it has;
the power to take away someone’s liberty without the commission of a criminal offence and the power to treat that person even in the face of their refusal. Because of that, we think that is important that the purpose of the powers is clear, as should be the basis on which they should be used.”
It is hard to disagree with that conclusion, especially given the number of people who are affected by those extensive powers.
I congratulate my hon. Friend on securing this debate, and on his personal and emotional contribution—I believe that adds everything. People living with dementia also fall under the Mental Health Act. There are concerns around section 117 and the right for aftercare support once someone is detained under the Mental Health Act, particularly those living with dementia. Does my hon. Friend share my concerns on that?
Certainly, there is insufficient support for a whole range of people. We have sadly seen a roll-back of support, independence of choice and control in a number of areas, including social care support, health services and direct benefits for some disabled people, particularly in the past nine years.
The extensive powers, which I described, were used to detain 50,000 people last year—a 47% increase in the past decade. The only other people detained in this country are those in criminal custody. Those citizens have safeguards to protect them from going to jail, but we do not have the same safe standards of support and safeguards for mental health care. Those who commit a criminal offence have a police investigation, the CPS evidence threshold, a trial, the right of appeal and advocacy throughout, but for the 50,000 detained under the Mental Health Act few such safeguards exist, despite the deprivation of liberty, choice and control.
We can turn this situation around. The independent review of the Mental Health Act, chaired by Professor Sir Simon Wessely, recommended that four principles be written into a revised Act. First, it recommended that choice and autonomy, even for someone detained under the Act, must be respected, enabled and enhanced wherever possible. Secondly, it recommended that the compulsory powers contained within the Act should be exercised in the least restrictive way possible. Thirdly, it recommended that services and treatments should be of therapeutic benefit and delivered with a view to minimising the need for Mental Health Act powers to be used. Fourthly, it recommended that the individual must be respected, and that care and treatment must be provided in a manner that treats them accordingly.
I seek the Minister’s views on those principles being incorporated in forthcoming plans. If those four principles had existed when my mum was detained—she has been sectioned more times in my lifetime than I can remember—I would have had more reassurance that her needs, rights and wishes would have been the starting point for the care and treatment she received. Sadly, that was not the case.
This is the first debate to be held on the Mental Health Act since that review was published, which is astonishing, given the level of use of the powers in the Act and the level of support for reform. The review made 154 recommendations. The Government accepted two immediately and agreed to publish a White Paper by the end of this year to bring forward full legislation. I welcome that; there is no one who does not want to see that. However, given the paralysis caused by Brexit, and the new Prime Minister and Cabinet, can the Minister can confirm that that timetable has not slipped?
It certainly should, but we should not have to wait for new legislation—some measures can be taken before that. Given that the White Paper is due by the end of the year, legislation many not come soon enough to help some of those young people who are experiencing problems now.
I hope the Minister will indicate that the Government’s rhetoric on parity of care will be matched by action on preventing the need for detention. Sadly, all the evidence points in the other direction. Parity of care—the requirement to treat mental and physical health equally—was enshrined in law in 2012 and became part of the NHS constitution in 2015. Although mental health accounts for 28% of the overall disease burden, as the NHS terms it, it received just 13% of NHS funding, according to the Centre for Mental Health. In cash terms, the King’s Fund has shown that between 2012 and 2017, funding for acute and specialist hospitals grew by almost 17%, while that for mental health trusts grew by just over 5.5%.
The Royal College of Psychiatrists has found that, taking into account inflation, the real-terms income of mental health trusts across the UK has fallen since 2011. It says that 62% of mental health trusts in England reported a lower income at the end of 2016-17 than in 2011-12. Sadly, only one trust experienced a rise in funding in all five financial years. The Royal College of Psychiatrists has also reported that mental health trusts received £105 million less in 2016-17 than in 2011-12, at today’s prices. There is no parity of funding, even though the Government are legally committed to it.
The 40% rise in detention over the past decade has come at the same time as a loss of overnight beds—between 2010 and 2017, the figure went down from more than 25,000 to less than 20,000—and a 15% decrease in the number of mental health nursing posts. Demand is rising as a result of detentions, but the number of staff has diminished and there is also less space available. The Care Quality Commission, which regulates mental health services, has reported that previously preventable admissions are now not being prevented because of cuts to less restrictive alternatives, such as community mental health services. There has also been an increase in the number of people with at-risk factors when it comes to detention, such as social exclusion and untreated drug or alcohol misuse.
Clearly, it is not in someone’s best interest to be detained if that is avoidable. A breakdown of mental health and behaviour can be deeply damaging for individuals, and their families and loved ones, but detention is extremely costly, especially compared with drug and alcohol treatment services or other interventions and support in the community. The average cost of each detention is estimated to be just over £18,000. The 50,000 detentions over the past year cost an estimated £900 million. That money could have gone so much further in earlier interventions to prevent detention.
Of course, there are also costs to how people are identified or present themselves in crises that result in detention. Sometimes they are homeless. I know the Minister has done a lot of work on that. We have met on several occasions and I know that she views homelessness as a public health issue—an issue that overlaps with the topic of this debate. Homelessness as a result of mental ill health increases physical health issues, which result in costs to the NHS.
Sometimes people in crisis are identified by the police. The last time my mum was sectioned—I think it was in 2016—she had had a car accident in which she hit a bollard. No one was injured, but she was prosecuted for the accident. My family and I—including my sister Alex, who I know is watching—had sought help for mum. We knew that she was becoming unwell and that she was not taking her medication, and we tried in advance to alert people to her need for support and to get her back on track, but that did not happen. She had agreed to plead guilty when the case went to court—she was guilty; she hit the bollard and no one else was responsible—but when she was asked how she would plead, she said that she could not be guilty because she had been wearing blue that day. Of course, that made no sense to anyone and resulted in the ordering of a psychiatric assessment, which was a pathway back into mental health care.
That was not necessary. Police and court involvement cause unnecessary cost to the taxpayer. If earlier interventions had occurred at the request of family members, that could have been avoided. I ask those hon. Members who have not been out with their local police and emergency responders to please do so. The last time I did it in Southwark, the police responded to a surprising number of 999 calls that involved someone with a mental health condition. That is not just anecdotal evidence; it is backed up by national statistics.
Troublingly, police statistics show an increased use of section 136 of the Act. That power is used by the police exclusively to remove
“mentally disordered persons without a warrant.”
Between 2015-16 and 2017-18, the use of that power in Southwark doubled, from 60 detentions to 121. That number fell slightly last year, but the shocking overall rise shows the price of underfunded mental health services, with the police often picking up the pieces in situations that should be handled by healthcare specialists and community interventions. Of course there will be some who are unknown to services, but most are not, and there are some who present with issues relating to suicide. Tackling the majority of cases upstream should be the target. I hope the Minister will state how that will be done through a White Paper or new legislation.
I welcome the previous Prime Minister’s commitment to end the use of police cells to detain people who are experiencing mental ill health. I hope that that commitment will continue under the new Government, because a police cell is no place for someone who is experiencing a mental health crisis. Although there has been a 95% fall in the use of cells and custody facilities since 2011, in the latest figures from 2016-17 they still accounted for almost 4% of detentions. I hope that the Minister will set out when the Government expect the number of people going through the system to be zero.
The point that I am trying to ram home is that overreliance on sectioning and detention can be bad for the individual and their families, but also for the taxpayer. We can do better than that. It is not just a matter of the loss of liberty; the Care Quality Commission has also sounded the alarm over risks for people when they are detained, including compulsory treatment and sexual assault. It reports that almost one fifth of patient records—double the proportion in the previous year’s study—
“showed no evidence of consideration of the least restrictive options for care.”
It also stated:
“We have seen limited or no improvement in the key concerns we have raised in previous years.”
That is the regulator saying, “Not only have we identified the problem this year, but we told you about it in previous years, and still no improvement has been made.” Its evidence shows that 1,120 sexual safety reports were made in a three-month period in 2017, of which 457 were about sexual assault or harassment of patients or staff. Some of our most vulnerable citizens are at risk of sexual assault while they are detained under the state’s powers. That is an absolutely appalling record in any civilised society.
These problems all undermine mental health treatment and use of the Act and make it no surprise that research commissioned by the Mental Health Alliance shows that individual experiences of being detained under the Act are far from positive. It surveyed more than 8,000 people, and the majority of respondents who had been detained did not believe that the Mental Health Act sufficiently protected them from inhuman or degrading treatment. Some 61% of respondents who had been detained disagreed with the statement, “People are currently treated with dignity when detained”, as did 41% of mental health professionals. The unity behind the case for reform and true parity of care could not be clearer. I hope that the Minister will cover those issues and confirm more of what the Government aim to put in their Bill when it appears, including human rights provisions.
At the Disability Rights Commission in 2004-05, I helped to bring organisations of and for disabled people together behind the principles that were then put in the Mental Health Act 2005:
“A person must be assumed to have capacity unless it is established that he lacks capacity.
A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success.
A person is not to be treated as unable to make a decision merely because he makes an unwise decision is made.”
Our right to make bad decisions is enshrined in legislation. I apologise to any smokers present, but they make a bad choice every time they light a cigarette, and arguably the Conservative party has chosen badly in selecting Boris Johnson. The fourth and fifth principles are:
“An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests.
Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action.”
We have precedent in legislation, and we need to support that approach again in reforming the Mental Health Act, with a resolute belief in patient-centred care, with as much choice, control and dignity as is humanly possible.
People’s experiences of being detained vary wildly. It cannot be right that some people are treated worse simply because the place where they become unwell does not have access to the right level of support. We need more standardised access to care, and more standardised care when it has to be provided. I recognise that detention cannot always be avoided, and that it has welcome results when people come out better than when they went in, but even when it is necessary, it must be done better—and there are ways to do that.
Advance decisions were one of the review’s two recommendations that the Government accepted. It is crucial that patients be involved in planning their care as much as possible. The Care Quality Commission’s research shows that under the current legislation, a staggering one in five patients detained have no input whatever in their care plans. It examined the plans in place for those patients and found that most of them were of poor quality, lacked planning and had no evidence of patients’ consent to treatment when they were admitted to hospital. Introducing advance choice documents so that people can set out their wishes about future care and treatment, and giving them more legal weight than they have under the current system, would help to solve that problem and improve care for thousands of people.
I will give a quick practical example for anyone who needs it. Medication for schizophrenia has improved dramatically. Some of the medication that mum used to take would cause regular, sustained vomiting, which caused teeth loss and worse. Different treatments are available. If she were sectioned and put back on that medication, knowing the side effects, it would obviously make the treatment worse for her. I hope that the Minister will give a strong indication about the Government’s plans for advance decisions and the ability to make choices that can improve the treatments available.
When a person is detained under the Act, they have a “nearest relative” who has certain rights to be involved in their care. Many family members and patients value the fact that relatives are given a statutory role, but that relative is chosen from an outdated hierarchal list that is based on age, rather than on the views of the individuals involved or on whether they have a good relationship. The Government accepted that recommendation from the review. I hope that the Minister will have more to say about that today—[Interruption]—and less about stopping Brexit, which is the chant outside that may have been caught on the microphones.
Those who are detained under the Act have effectively no legal say over their treatment and no automatic right to advocacy in the event of their detention. The fact that such rights are not enshrined in the legislation illustrate that reform is badly needed. Establishing a right to an advocate for all mental health in-patients, whether voluntary or detained, without having to ask for one, would also radically improve care, as would the statutory inclusion of a patient’s advance wishes in their treatment plan. I hope that the Minister will give an indication on that matter today as well.
I will cut down the bit of my speech about resources, because they have already been mentioned and I know that other hon. Members want to speak. However, cuts have had serious implications, including for the distances that people, including children, have to travel for treatment: they are often taken hundreds of miles away from their friends, family and community. That cannot be acceptable. Wider cuts to council budgets and the public health agenda have also had an impact, and my constituency has experienced the knock-on effects. We lost an organisation called CoolTan Arts, which used to provide creative and employment support for many disadvantaged people with mental health conditions.
My very real fear is that the bad old days have crept back. For too long, Ministers have ignored the problems. There have been cuts to services, and we are seeing more ill-trained or morale-sapped staff; an overuse of agency crews; rising use of detention, which locks the problem away out of sight; and compulsion rather than empowerment. That must change. The new Prime Minister must listen to what is said in this debate; I hope he will. The White Paper that has been promised must be delivered and must reflect the spirit and ambition of the independent review.
New legislation must also be passed to update the Act. It is not just about getting a better piece of legislation; more importantly, it is about better treatment for the thousands of people with mental health conditions and their families up and down the country. There is cross-party support for this work: 49 colleagues have signed early-day motion 1242, which
“calls on the Government to reform the Mental Health Act…during this Parliament”.
There is appetite in the Commons for that reform, so I hope it will be delivered.
We have a window of opportunity to improve thousands of people’s lives. I hope that the Minister and the new Cabinet and Government will take it.
Thank you, Ms Buck, for calling me so early in this debate. I am sure that I speak for everybody who listened to the remarkable speech of Neil Coyle when I say that it was a privilege to do so. We should all be immensely grateful to him for illustrating the important policy points that he had to make by means of his agonising experiences in his immediate family in his very early years. We all thank him for it.
Given how many hon. Members wish to contribute, I will speak very briefly. I note that the hon. Gentleman’s speech was briefly interrupted by some shouting outside the Chamber to do with Brexit; it seems to be a common theme that mental health debates tend to happen at times when they are overshadowed by other issues. For example, when I became a Member of this House in 1997, I came second in the private Member’s Bill ballot. I chose to introduce the Mental Health (Amendment) Bill, which was designed to achieve improvements for people who suffered catastrophic breakdowns such that they needed to be admitted to acute mental health units.
At that time, the person who came first in the ballot chose to address a subject of massive national importance, namely the banning of hunting with hounds, and I could not help but notice the contrast between the packed main Chamber on the Friday that was considering the welfare of foxes and the rather more thinly occupied main Chamber a week later, as was customary, when we were trying to consider the welfare of human beings. It was ever thus.
The points at issue then are, to some extent, still points at issue now. They have already been touched upon, at least in part, in the excellent opening speech that we have all heard. My particular concern was the need for there to be separate therapeutic environments for people who had to be admitted to acute units who suffered from very different types of mental illness. In other words, the idea that somebody suffering from acute depression should be cheek-by-jowl with somebody suffering regular psychotic outbursts was obviously a recipe to make a very serious situation even worse.
While I was doing the research for that debate, it was drawn to my attention by staff at acute units that their particular nightmare was the thought of what would happen if there was inadequate staffing coupled with mixed-sex wards. I was really rather shocked and shaken today to hear the statistics cited by the hon. Member for Bermondsey and Old Southwark about the level of danger of sexual assault among in-patients, because for quite a number of years I and various other colleagues waged a campaign to abolish mixed-sex wards in mental health in-patient facilities. At first there was talk of separate bays, if I recall correctly, which by no means would have answered the necessities of the problem. And successive Governments kept saying that they would do it, and even that they had done it, so it is particularly disturbing to hear about the level of concern that still exists about this issue.
The question of inadequate numbers of beds has already been touched upon by the hon. Gentleman. It has to be said that, for once, this is not the responsibility or fault of Government, because after the closure of so many of the large asylums, the pendulum—in my opinion, and I am not an expert; I have to say that I am not a medical doctor—swung too far the opposite way.
I remember, in the New Forest area, having to fight a bitter campaign—which ultimately failed—to prevent a 35% reduction in in-patient beds in acute units. If I remember correctly, two of five units were closed. We were prepared to compromise and say, “Close one of the two units. Close 16 of the beds, rather than 32, and see how you get on,” but the authorities would not listen and they forced the closures through. It was the Southern Health NHS Foundation Trust, which later became notorious in the mental health sphere for other reasons, that forced through the closure of all these beds, and the system has been rammed and overflowing, and under excessive pressure, ever since.
There was another knock-on effect of the swinging of the pendulum too far back from the correct policy of closing the larger asylums, and that was that, by having fewer permanent facilities, we lost the ability to have what was technically—or maybe not very technically—known as the “revolving door”. This was the idea that, yes, if we could get more people back in society, so that they could make their own way and live their lives freely and without having to be in-patients, the very existence of a network of permanent establishments—albeit for other purposes—meant that there were always plenty of opportunities, so that if somebody felt that a trough was coming they could seek help easily for, as it were, almost a top-up of treatment, just for a few days. That would then set them back on track and it meant that they would not suffer—
I am delighted to see the hon. Member for Bermondsey and Old Southwark indicating his agreement. It meant that they would not then suffer a much worse breakdown, which would have meant that they would have to be incarcerated, for want of a better word, for a much longer period.
To prevent people, including people living with dementia, from having to be admitted to hospital, there needs to be community support and after-care support once people are discharged, to ensure that they can be kept as healthy and independent as possible in the community for as long as possible.
The hon. Lady is absolutely right, as long as we recognise that what is needed is a range of facilities. Even the most ardent advocate of doing away with in-patient beds would, if pressed, admit that there will always be some people who at some point absolutely need to have some in-patient treatment.
If there are some people who need to go in for a considerable period of time, and hopefully there are a lot more people who do not need to be admitted to acute units at all, it follows almost logically that there will be some people who are on the borderline between the two, who can get by in society with a degree of self-awareness—either their own or that of their immediate family—and that when the warning signs appear, provided there is that network of specialist care with beds for very short-term stays, they can receive what I call a “top-up”, or, if we were talking about servicing a vehicle, something that will prevent a much greater collapse from happening later, with all the consequent horrors.
The question of what happens when people are admitted to acute units arose on a second occasion. I mentioned the first occasion, when I tried to introduce my private Member’s Bill in December 1997 and it was overshadowed by foxhunting. On a second occasion—on
On that occasion in December 2010, I raised the case of the daughter of my constituents, Mr and Mrs Edgell. Sadly, their daughter—who was called Larissa but known as Lara—had taken her own life in 2006. For two years prior to that, the medical authorities had refused to share information about her with her parents; because she was an adult in her thirties, they refused to share vital information about her suicidal thoughts with her parents, on the grounds of patient confidentiality.
It subsequently turned out that there were very good guidelines that said that such information should be shared. So, I wrote to the then Minister with responsibility for care services, Mr Lewis, saying that there was clearly a breakdown in the system if adequate rules existed but were not being put into practice locally. The rather unsatisfactory answer that I received at the time was that the responsibility lay with the local medical authorities to ensure that the central guidelines were implemented.
As I say, that was at the end of 2010, so it was a long time ago. I wonder whether the Minister will be able to reassure me that there is now more central direction. In the case of Lara and her parents there was inadequate sharing of vital information, under the mistaken belief that patient confidentiality trumped the fact that an adult patient was incapable of making her own decisions. I would like to know whether that situation has been rectified, or whether we are still dependent on local medical institutions and authorities to apply a central guideline that ought to be better known.
This week, I received a letter from Lara’s mother, who asked me to attend this debate. I can do no better than to read from what she says, not so much about what happened to her daughter but about the continued interest that she has in the workings of the mental health services. She says that she would like to make her own recommendations; given what happened so tragically in her immediate family, we owe it to her to give serious consideration to those recommendations, which are as follows:
“1. The 1983 Act should be revised to prioritise the dignity of individuals who come to be in the Service’s orbit.
2. Such individuals should have their values and world views respected and have a significant say in the manner of their treatment.
3. They should have the option to refuse certain treatments.
4. Mental hospitals must be places where patients feel safe: there have been numerous allegations of staff members being abusive, provocative and/or intimidating.
5. Use of force should be absolutely minimised. This includes physical restraint, seclusion, or forced medication.
6. A reduction in ‘sectioning’.
7. A reduction in stigma”— and finally:
“8. All aspects of the Mental Health Service should be more open, and subject to independent scrutiny from time to time.”
I will conclude by making one left-field observation relating to the armed forces. The Select Committee on Defence, which I have the honour of chairing, has been recommending for some time that we establish a centre of excellence for the mental injuries suffered by those who put their life on the line to defend this country, preferably alongside the national centre for physical rehabilitation at Stanford Hall. We have now raised this issue twice with the Secretary of State for Health and Social Care, who has given us a reasonably encouraging response. However, once again, we feel that he is coming up against resistance because of the philosophy that people must be treated locally when at all possible, not admitted as in-patients in centralised locations. That is causing a pushback against our idea.
Our idea is based on the fact that those who suffer injury in combat situations have experienced a peculiar and unique form of trauma, different from those that ordinary mental health professionals can be expected to understand. I am sure that my hon. and gallant Friend Johnny Mercer will want to expand on that topic, if he is lucky enough to catch the Chair’s eye. We believe that there is a case for a national centre of excellence, and that the welfare of members of our armed services who suffer mental injury should be no less important to us than the welfare of those who suffer other, physical forms of injury in the cause of defending our freedom.
As always, it is a pleasure to see you in the Chair, Ms Buck. I congratulate my hon. Friend Neil Coyle on an incredibly powerful speech that was very detailed and knowledgeable about this issue. Obviously, my hon. Friend was speaking from personal experience, which was very brave of him.
It is clear from the findings of the independent review of the Mental Health Act, published last year, that the current legislation needs significant reform. There has been a 47% increase in detentions under the Act over the past decade, while the proportion of people living with a serious mental illness remains relatively unchanged, so clearly there is some imbalance there; it cannot be right that the number of detentions is going up. I echo the points that have been made about the link between this issue and the cuts to, and failings of, other services in the community that might be able to help at an earlier stage. Perhaps that is one reason why people are ending up in the most serious of circumstances; that is, being detained.
Being detained in a secure mental health unit is obviously going to be an intimidating and frightening experience for anyone. However, it is particularly intimidating for people with learning disabilities and autism, especially young people with those conditions, so I will focus on those groups in my speech. I raised this issue at Health questions on Tuesday, and the Minister—not Jackie Doyle-Price, but another Minister from the Department of Health and Social Care—gave a very thoughtful response.
One of the things that the Minister said was that learning disabilities, autism or other special needs are often not diagnosed until a child is detained in a mental health unit, which again shows the failings. Child and adolescent mental health services are incredibly under-resourced, and schools are really stretched when it comes to education, health and care plans and working with children who show signs of mental health problems. It is so important that we put proper resources in, so that we can give those children the help they need as early as possible. I am sure that the Minister responding to today’s debate, the hon. Member for Thurrock, agrees with that.
Under the Act, people with learning disabilities and autism can be sectioned with no mental health diagnosis if they are displaying challenging behaviour. The independent review found that the Mental Health Act was
“being used inappropriately for people with a learning disability, autism or both, to deal with a crisis that has arisen because of a lack of good community care or placements…It is particularly intimidating for a person with autism, learning disability or both to be removed from a place they are familiar with or from people they know, even if at the time there seemed little alternative…Instead of improving their mental health, the environment (including relationships with staff) has made them worse, not better.”
One of the common characteristics of autism, for example, is being wedded to routine, and being uncomfortable with unfamiliar circumstances and stimuli that those people would perhaps not get in a more protective environment. That can be particularly challenging.
The Equality and Human Rights Commission echoes such concerns, stating:
“The Commission is concerned about the lack of suitable provision for people with learning disabilities and autism, who may be in restrictive institutional settings because there is insufficient community-based support. The Government failed to meet its minimum target to reduce the number of people with learning disabilities and autism detained in inpatient settings, and at the end of March 2019 there were still 2,260 children and adults living in these institutions. On average, they had spent almost 5 and a half years detained away from home. There were more than 2,600 restrictive interventions recorded against inpatients with learning disabilities and autism in a single month, including physical, chemical and mechanical restraint, seclusion and segregation. Of these, 875 interventions were used against children.”
Most of those people should never have had to go into an in-patient unit, let alone be subject to those types of restrictive intervention. They are ending up in such units because of challenging behaviour due to unmet needs in the community. Those needs, as I have said, should be met with vital investment in community mental health services.
From my experience of people who have come to my surgeries, other casework that we have been dealing with and what I have picked up from visiting institutions, it seems that mental health services suit certain people because of the pathways developed in the NHS, but others do not fit into that category. For example, a child with learning disabilities was rejected for anxiety counselling, and they were later diagnosed with autism. To do the standard CAMHS anxiety counselling, someone has to have a certain ability to rationalise their actions and think about how they operate. That cognitive behavioural therapy-type approach was not suitable for that child, but that meant that nothing was available, because that was the pathway for young girls suffering from anxiety.
I had another case where a constituent was told that she was too traumatised by a recent experience to go through the counselling on offer through her GP. She clearly was not in a serious enough condition to be sectioned, however, so it seemed like she was caught between two things. She clearly needed help, but she was deemed to be too serious a case to get the help that was available. We need to look at the people, rather than just trying to fit them into categories and, when they do not fit into categories, rejecting them from the system, almost as though we are saying, “Come back when you are a lot worse, and then perhaps there is something we can do for you.” That has to be the wrong approach.
Going back to children in particular, the UN Committee on the Rights of the Child has expressed specific concerns about the adequacy of therapeutic community-based services for children. Because of that lack of community provision, children are being detained when they should not be. According to NHS Digital, at least 1,777 people aged 17 or under were detained under the Mental Health Act in 2017-18. Of those, more than a thousand were admitted to a non-local bed, in many cases more than 100 miles from home. Some children and young people under care of Bristol, North Somerset and South Gloucestershire CCG had to travel up to 243 miles away from home for mental health care. That cannot be in the child’s best interests and will add to the sense of isolation and anxiety, and it can also prevent their families from being properly involved in their care.
A recent Children Commissioner’s report found that many parents feel they are being shut out of decisions about their children’s care and are not always informed about incidents involving their children. Serious incidents had happened in hospital without families even being told. Some families had even faced gagging orders where they had been prevented from speaking out about their children’s care. The independent review calls for better safeguards to protect children and young people, ensuring that they are treated in hospital only when necessary and that their rights as a child are clearly set out. There is a need to establish clear tests as to whether children and young people are able to consent to hospital admission or treatment and whether they should be involved in decisions made about them. Clear roles need to be established for parents in care planning and treatment.
The review also states that there needs to be more advocacy available for children and young people. That is particularly important where conflicts arise between the clinical team about how to meet the best interests of the young person, including where contact between young people and their parents is seriously restricted—in some cases, the mental health crisis might be the result of chaotic family circumstances at home or ill treatment—or where the wishes of the young person conflict with the wishes of the adult.
Every in-patient child or young person should have a personalised care plan that includes their views and wishes and access to an advocate. They should be regarded as a child in need under the Children Act 1989 so that parents can ask for help from their local authority.
As the British Medical Association lead for mental health, Dr Andrew Molodynski has said:
“Warehousing unwell people in locked wards far from home goes against the very nature of mental health rehab—to help them reintegrate back into society.”
Unnecessary detention of vulnerable patients is not only unhelpful in terms of their recovery, but an ineffective use of taxpayers’ money. Too much money is being given to private firms to look after people with serious mental health problems in units often hundreds of miles away from their homes due to a shortage of NHS beds. That figure was £158 million in 2016-17 and £181 million in 2017-18—an increase of £23 million.
Last year, an extensive study of mental health rehabilitation by the Care Quality Commission found that stays in private beds cost twice as much as in the NHS because they tend to last twice as long. It found that the annual cost of rehab was £535 million and that private beds were on average 30 miles away from patients’ homes, whereas in the NHS they are only nine miles away.
One of the cases that I have been dealing with recently is that of a child who is in a mental health unit 150 miles away from home, but the unit closest to her home is in special measures and not accepting new patients. However, the unit she is in is ranked as outstanding and she seems to be making good progress. Clearly, when parents are faced with such a choice, they want their child to go to the best unit possible, but that can put huge pressures on a family, in particular when they have other children, as well as jobs and lives. They might also not have the money to decamp to somewhere so they can visit their distressed child each day. There is a real lack of support in the system for families placed in such circumstances, with their whole lives disrupted by trying to be in two places at once.
Another problem is that the quality of care in hospitals can be highly variable. The Whorlton Hall case demonstrated just how awful situations can be, and how badly people can be treated in some places. In a recent investigation into children with learning disabilities or autism living in mental health hospitals, some families told the Children’s Commissioner about the excellent support that their children had received—it is important to put on the record that there is good care out there—but others had shocking stories to tell. For example, one family said that their son had not been washed for six months while in hospital. Basic care needs were not being met.
Despite improvements in recent years and the drive towards parity of esteem between physical and mental health services, it has not been realised. The aspiration is noble and shared by both parties, but we need to invest far more in our mental health services for people to get the support they need. I welcome the fact that the need for better community services was highlighted in the recent NHS long-term plan, and I am pleased that the Government have committed more funding to severe mental illness and to greater use of alternative mental health crisis provision, such as crisis cafés. However, an overhaul of the Mental Health Act is clearly needed if that investment is to be used in the best interests of patients by ensuring that their dignity and rights are protected and that they are treated in hospital only as a last resort.
The previous Prime Minister committed to new legislation to bring the Mental Health Act into line with a more modern understanding of how best to treat mental health. She confirmed that a White Paper would be published before the end of the year. The Minister is probably wondering whether she will be in post by the end of today, but even if she is moved on to greater things, I hope she asks the new Prime Minister to give that the same priority as the previous Prime Minister did.
It is a pleasure to serve under your chairmanship, Ms Buck; thank you for calling me to speak. First, I pay tribute and give my thanks to Neil Coyle for securing the debate. Some of the best days we have in this place are when people recount their personal experiences and what drove them to the interests and causes they have in this place. It was remarkable listening to his experiences, which reinforced why we need to move what we do on mental health away from having a good conversation to actually changing things in a way that means something in the communities we serve.
With a new Prime Minister just two days into the job, it is a welcome opportunity to put this important issue on the agenda before summer recess. I look forward to the Government delivering on the White Paper that they have promised to publish by the end of the year. Mental health is an area that I have been trying to make a difference on since I came into this place. I have spoken openly about my own experiences of obsessive-compulsive disorder. I have said before that while I might like to pretend it is a distant memory, those who know me well know that it is not.
Reforming the Mental Health Act 1983 matters to me because I think it is important that we give specific, considered attention to the people whose mental illness is so severe that the state needs to step in to protect them or potentially other people. When people are unwell they need support. The 1983 Act provides that, but as I recently discussed at an all-party parliamentary group on mental health event on that very topic, that support is not always as beneficial and therapeutic as it might be.
Members will know that I am chair of the all-party parliamentary group on mental health. At the event I mentioned, we were pleased to welcome Sir Simon Wessely as one of our speakers. His speech was very informative about some of the key changes that the review recommends and where we are at politically in making the new vision a reality for those who suffer with their mental health in our communities.
One thing that stood out to me in Sir Simon’s address to the group was that, while rates of detention have increased, the rates of severe mental illness have remained relatively stable. Gold standard studies such as the adult psychiatric morbidity survey show that, so how do rates of detention shoot up by 47% in the last decade when the rate of mental illness among the population is almost unchanged? Something is not working, and I welcome the review’s recommendation to raise the bar and tighten up the criteria for detention.
We were also privileged to hear at that meeting from Georgi Lopez, a young woman who bravely shared her experience of being detained under the Mental Health Act with members of the APPG. Her powerful testimony made it clear that legislative reform is required to change things for the better. I will share some of Georgi’s story with the House to illustrate how the Act negatively affects some people’s lives when they are vulnerable and very unwell. I thank the hon. Member for Bermondsey and Old Southwark for sharing his experiences of the Act. We must keep such stories in mind when we talk about the potential of the forthcoming White Paper.
Georgi is 23 years old. She was first detained under the Act when just 17, and was detained for the majority of the next four and a half years. Georgi was diagnosed with anorexia nervosa shortly after completing her A-levels. She had been preparing her application to the University of Oxford. Shortly after her AS exams, she was taken to A&E, as she was severely dehydrated and malnourished. Her parents were given an ultimatum: to have Georgi voluntarily admitted to a psychiatric hospital or for her to be sectioned. They chose voluntary admission.
For the first few weeks in a psychiatric hospital, Georgi complied with all the treatment she was given, but following her first meeting with a psychiatrist she was told that she would be assessed to be detained under section 3 of the Mental Health Act. She was also put on highly sedative medication. She and her parents objected to her being detained because, up until that point, she had followed her treatment plan as asked, without need for coercion or detention. They were not listened to and she was detained.
Hon. Members can imagine how someone who has done everything that they have been asked to do to manage their condition would feel on having that control taken away from them, with little to no reason given. Georgi dealt with that loss of power by declining to take the medication that she had been prescribed. She was then forcibly injected with sedatives. That experience shows why Professor Wessely’s report is aptly titled “Increasing choice, reducing compulsion”.
I later heard about Georgi’s second experience of detention, which was completely different. She said that she was treated like a human being, and the staff were very interested in her past, her interests and her aspirations. Her care team involved her and her family in every decision about her treatment. Although it took her some time to rebuild her trust in the system and the Act, she believes that she owes her life, health and happiness to that positive experience, where she had choice and autonomy.
Georgi was clearly right when she told our APPG that her first experiences of treatment were neither caring nor conducive to her recovery. I agree with her, but her second experience, where her team involved her in her own care and helped her to rediscover herself and her identity, shows that it is possible to provide good psychiatric care. Georgi is in fact now an aspiring psychiatrist. People think that it gets easier to share your story; it does not—it always takes courage and bravery. I hope that by listening to Georgi’s varied experiences of the Act we can see that, although it is possible to provide care that involves patients in decision making, that does not always happen.
The Act shapes the culture and practice in mental health units. We need to change it so that Georgi’s positive experience of the Act is standard across the country. I fully support reform and I am pleased that the Government have committed to a White Paper by the end of the year. We need to seize the opportunity to get this right, and I am sure that our new Prime Minister will show leadership on this issue, which is important to my party and my constituents.
It is a pleasure to serve under your chairmanship, Ms Buck. I put on record my thanks to my hon. Friend Neil Coyle not only for securing the debate but for the way in which he introduced it. I agree with Johnny Mercer that someone speaking so powerfully brings to life what might be dry words on paper in an Act. To hear the experience that my hon. Friend and his family have been through highlights why it is important that we get things right.
My hon. Friend described how the Mental Health Act 1983 gives the state draconian powers to detain individuals and take away their liberty, not because they have done anything wrong but because they are mentally ill. As he said, 50,000 of our fellow citizens go through that process every year. There is something wrong if we are using the Act 50,000 times a year. I am sorry, but I just do not accept that in 2019 that is the only way we can deal with someone in mental health crisis who, rather than being a danger to anybody else, is possibly more of a danger to themselves.
Like others, I accept and welcome Professor Simon Wessely’s report. As my hon. Friend said, some of us remember the 1983 general election. It was a long time ago, but there are some similarities, as he said, with the current political world. Importantly, things have changed, including our attitudes on a whole range of things. The key issue that comes out of Sir Simon Wessely’s report is the need to put the individual at the centre of everything. The hon. Member for Plymouth, Moor View gave a very good example of how, when we get it wrong and do not put the individual at the centre, things are bad for that individual. Clearly, his constituent was treated inhumanely. We must put people at the centre. That is difficult, as people who are in mental health crisis can have great difficulty in making decisions, but that does not mean that they have lost capacity in all circumstances. That is one of the things that Sir Simon raised in the report.
The use of the Act should be a last resort, not the first course of action in dealing with people who are in mental health crisis. As the report says, we also need to involve the individual in decision making. That can be difficult; I accept that people can refuse treatment. However, if it is properly explained and people are involved in the decision, there are better outcomes for them individually and in-patient time will be reduced.
I have spoken before about advocacy. Owing to the draconian powers that the Act bestows on the state, it is important that the individual has access to independent advocacy. I welcome the recommendation for people to have to opt out of having an advocate. That puts the onus on the state to have independent advocates trained and available, and to ensure that people know how to access them.
My hon. Friend the Member for Bermondsey and Old Southwark also raised the issue of family members, which can be very difficult. The report’s suggestion to move towards having a nominated person is the way forward. In the past, assumptions have been made that an individual wants certain relatives involved; on a number of occasions they do not want that, and it may not be in their best interests. The right hon. Member for New Forest East (Dr Lewis) made the point that we need to try to involve family members where we can, because they are an important part of supporting the individual and ensuring that they get the help they require.
I am concerned about a lot of issues related to the Act, including the need for a timetable for implementing the recommendations. A White Paper has been promised. I do not criticise the Minister because, as I have said before, since she has been in post she has been a strong advocate for mental health issues. However, this matter has to be a priority. I know we can get blindsided by big issues regarding Brexit, but the implementation of these changes is important and should be a top priority.
The report states that we need to investigate why the Mental Health Act is used more against members of black, Asian and minority ethnic communities than others. I accept that there may be a stigma attached to mental health issues in certain BAME communities and that it might give rise to particular questions, but that topic needs an inquiry all of its own. Unless we get answers to why the Act is being used more in those communities, we will not be able to make the necessary changes.
Why is the Act being used more? Perhaps there is a simple answer. Ever since we closed the asylums in the early 1980s, we have put neither the investment nor the policy in place to support people with long-term enduring mental health conditions in the community. That is about money to pay for the support that individuals need, but it is also—my hon. Friend Kerry McCarthy raised this point—about pathways, how people get into the system, and the disconnect between the various agencies with which people come into contact.
The all-party parliamentary group on social work has just conducted an inquiry on that subject. I am not going to steal the thunder of my hon. Friend Alex Cunningham, who chaired the inquiry. It was very informative, and I was privileged to be involved in it. The disconnection and lack of integration between local councils and the health service is clearly an issue, and it is not necessarily just down to money; it is also to attitudes. The system needs to be put back together. It is no good telling somebody who is in a mental health crisis, “I’m sorry, but you are not my responsibility; that is a local authority issue,” if they present to the NHS or vice versa. That needs to be put right.
In County Durham we have a very good integrated system of local government and NHS care, which works very well. If we are to put that wraparound care around individuals such as the mother of my hon. Friend the Member for Bermondsey and Old Southwark, it must be integrated; it must be joined up. It cannot be fragmented.
Is the problem all about the availability of beds? I would say no, it is not. The right hon. Member for New Forest East is right that we have cut beds back too quickly, thinking that we do not need them and that we can manage people in the community when we cannot. The argument that follows is, “The answer to this is more beds.” Well, I am sorry, I do not think it is, personally. What I want is a good community-based model to support people in the community. That is going to take money. It needs a clear, worked-through policy. It has to include local authorities and it has to include housing. One of the biggest issues that people leaving in-patient beds face is the question of where they will live, and it is not surprising that many of them end up on the streets in our communities. We need a joined-up approach.
As I said earlier this week in another debate on mental health, we must have a joined-up local system that includes not just the agencies I have mentioned, but the community and voluntary sector. If we are going to support people in the community, in my experience it is often best done by voluntary and community sector organisations. As my hon. Friend the Member for Bermondsey and Old Southwark said at the beginning of the debate, many of those organisations are under pressure because grants are being cut. We need a joined-up approach.
While I am on my hobby horse about the voluntary and community sector, can such organisations bid for contracts from clinical commissioning groups and local authorities? In many cases they cannot, because they are not big enough. The contracts are drawn up in such a way that they are not available to those organisations. In terms of value for money and local input, that would be very important.
We must also support and develop staff in the sector. During the inquiry, we met some amazing, inspiring young people who were entering social work and majoring in support for people with mental health issues. In Durham a few weeks ago, I had the privilege of meeting some of the young people who were taking part in the Think Ahead programme—I think it was started by one of the Minister’s predecessors—which aims to get social workers trained in mental health work. Most of those I met said it was a very rewarding field to get into, when it was properly supported.
What about other Government policies? We need joined-up policy at the local level to support individuals, but we also need to make sure that mental health is hardwired into Government policy. I have said that on a number of occasions, and I will do so again. For example, if someone in the community has a long-term mental health condition, fails her personal independence payment assessment and is sectioned—I handled a similar situation a few weeks ago—what does that cost the taxpayer? It is no good for the individual and it is no good for the taxpayer. Under mandatory reconsideration, the PIP was reinstated. We have to make sure that consideration of mental health issues is built into policy and that the policies of other Government Departments are not creating problems for individuals.
Finally, as we know, many individuals in prison have mental health problems. The current system for transferring individuals from prison to mental health facilities is not working. That is another issue that I have raised previously. Those on indeterminate or fixed sentences who come up for assessment by the Parole Board face a double jeopardy situation. They have to have a mental health assessment by both a mental health tribunal and a Parole Board. That cannot be right. It leads to, on average, an extra 18 months in prison, where proper treatment and proper planning is difficult. It does not help them or the system, and it costs more to keep them in prison. We need a system where one single assessment would be enough to make sure that those people get the support they require.
This is about money and it is about reforming the existing system, but we must also ensure that both national and local policies enable a joined-up, wraparound service. With the right investment and the right political will, we can get there. We are not going to go back to putting people in institutions or asylums; people should be able to live a happy, contented and safe life in the community, with the wraparound care that they deserve. That is what we should be providing, as a decent society.
It is a pleasure to serve under your chairmanship, Ms Buck. I congratulate my hon. Friend Neil Coyle for a very moving opening speech. It was a very brave speech, because he was sharing difficult personal experiences, and that made it all the more compelling.
I want to focus on the use of restraint, which is one of the four key issues that the review covers. Last year, Parliament passed my private Member’s Bill, which became known as the Mental Health Units (Use of Force) Act 2018, but is better known as Seni’s law. I was very grateful to the Minister for her support on the Bill, which introduced a system for reducing the use of abusive and coercive restraint in mental health settings. It establishes in law, for the first time, some very important principles, including the need for trauma-informed care. Some of the principles in the Act, which was of necessity relatively narrowly drawn, could and should be applied more widely. That is the point I hope to impress on the Minister this afternoon.
Perhaps I can remind colleagues of the human story behind Seni’s law—the Minister knows it, but other colleagues might not. Seni Lewis was a young graduate aged just 21. His parents found him having a traumatic mental health episode at home one Sunday morning, something he had never experienced before. They took him to the local hospital, expecting to find the care that he needed and deserved. He ended up at the Bethlem Royal Hospital, where his parents stayed with him until late evening before leaving to go home. Seni became very alarmed when he found out that he was alone, and he tried to leave. The hospital staff decided to section him and therefore tried to stop him leaving.
There were never any allegations that Seni threatened or assaulted anyone, but the hospital called the police. It ended up with 11 police officers dragging Seni, with his hands cuffed behind his head and legs in braces, into a seclusion unit, where they took turns sitting on him as he was pinned down on the floor. Seni’s spinal column was broken and he went into cardiac arrest, then into a coma. He died shortly afterwards.
Looking at the pictures of people who have died in mental health detention, we see many young black faces like Seni’s. Widely held prejudices about young black men and psychosis, drugs and aggression lead them to be subject to more severe treatment than other patients. In extreme cases such as Seni’s, it leads to death. It is a form of institutional racism, and we need to call it out and confront it.
I first met Seni’s parents three years after his death, just after I had been elected to Parliament in a by-election. They came to see me three years after this terrible incident because there had still been no inquest into his death, no public explanation of how or why their beloved son had died, no learning to prevent similar deaths in the future, no closure and no justice for Seni’s deeply distraught family. It was only after a very long public campaign and the intervention of the then Minister for mental health, Norman Lamb, and the then Home Secretary, Mrs May, that an inquest was finally opened, seven years after Seni’s death. It found that Seni had been subject to severe and prolonged restraint that had caused his death. It castigated the police and the mental health services and warned that, without change, other people in the mental health system would die in the future, just as too many have died in the past.
Seni’s law began as a cross-party attempt to start the process of change by creating a new national system for recording the use of restraint in mental health settings. We will soon be able to see what is happening in different mental health trusts and hospitals, and compare like with like to identify and spread best practice in reducing the use of abusive and coercive restraint. However, the same system needs to be extended to all settings where people with mental ill health might be subject to restraint, and I invite the Minister to comment on any plans she has to do that.
[David Hanson in the Chair]
The review makes it clear that we need to do more. Deaths in mental health settings should be investigated in the same way as deaths in any other form of state detention are investigated. When someone dies in prison or in a police cell, there is an automatic external investigation by an independent national body, which publishes a final report and shares what it has found. However, when someone dies in a mental health setting, as Seni Lewis did, there is no such fully independent investigation. In Seni’s case, the health trust investigated itself, and lessons that needed to be learned were not learned. Owing to errors by the Independent Police Complaints Commission, the Metropolitan police were able to block an inquest for a full seven years after his death. It should not be possible for the organisation under investigation to control the scope, timeliness, quality and content of the report on their own potential failure, because of the risk of a cover-up.
I pay special tribute to the powerful campaigning work on this issue that has been carried out by the charity Inquest. I fully support its demand for non-means-tested legal aid to be available to families at inquests, so that there is a level playing field between the bereaved family and the well-funded organisations accused of potential wrongdoing. Such investigations must be conducted by fully independent bodies that command the confidence of the public and bereaved families. By failing to learn from preventable mental health deaths, we condemn other vulnerable people to the same tragic fate.
Seni Lewis died in the most horrific circumstances, and his parents then had to fight for justice over seven years, just to find out what had gone wrong. Seni’s law stands as a testament to his life, but it is time to go further. The review of the Mental Health Act 1983 creates an opportunity to do so. We need to ensure that every bereaved family can get the justice they deserve. We need to ensure that, through a fully independent system, every lesson we need to learn is learned and acted on, so that we can keep every vulnerable person with mental ill health safe in future.
It is a pleasure to serve under your chairmanship, Mr Hanson, and to follow not just the contribution from my hon. Friend Mr Reed, but the other speeches. Great expertise and understanding has been brought to the debate. I congratulate my hon. Friend Neil Coyle on securing the debate, and I thank him for sharing a very powerful and personal testimony as well as offering solutions to the crisis in mental health. So often we can blather away in places such as here in Westminster Hall; we can talk about the problems, issues and suffering, but sometimes we do not offer solutions. It is our job to come up with solutions, and my hon. Friend the Member for Bermondsey and Old Southwark and others have offered some.
As some colleagues might know, I have the privilege of chairing the all-party parliamentary group on social work. As my right hon. Friend Mr Jones said, we recently undertook an inquiry on the role that social workers play in upholding the principles outlined in the independent review of the Mental Health Act 1983, and on how that role can be recognised and enhanced in new legislation.
I believe that social workers are regularly, if not always, undervalued, yet their work is incredibly valuable in supporting and helping the most vulnerable people in our society—be it children at risk, older people in need of a bit more support, or families who experience breakdown and need the independent support that a social worker can provide. Of course, social workers also support people with mental health needs, although many people do not realise the tremendous role that they play in that. They ensure that mental health problems are not a barrier to anybody achieving the things they want, and that people get the appropriate treatment and care that they need.
Back in 2018, I met with two approved mental health professionals in my role as the chair of the APPG on social work. They are known as AMHPs—perhaps it is something to do with their electrifying personalities. They explained that there was a need to promote the role of social workers in mental health services, and I now understand why that is necessary. The legislation and policy often skim over the work of social workers, perhaps because it is so varied and hard to pin down.
In December, the independent review of the Mental Health Act 1983 published its report and recommendations. In preparation for a Government response, the APPG decided to have our own inquiry and add to that great piece of work. Some 9,000 social workers work in a defined mental health role, accounting for about 4% or 5% of the core mental health workforce, and 95% of AMHPs are social workers. I know it will take more than legislation to embed the kind of changes we would like to see, and work will have to be done by CCGs, local authorities, the NHS and social work leadership—to name but a few—if we are to succeed and get the change that is needed. I am hopeful that the APPG’s report and recommendations will act as a staging post on the way to cultural and legislative change.
Was my hon. Friend impressed, as I was, when we met various people giving evidence to the inquiry? The best practice was where local authorities and the NHS were co-located and working closely together, rather than when it was being divided.
Yes, that was most certainly the case. I shall remark on that a little later in my speech. I was really concerned to find that the number of joint working arrangements was diminishing rather than increasing across the country, but I will address that a little later.
I was surprised to hear in the evidence sessions that health and social care integration, which the Government are officially pursuing, is going backwards. My right hon. Friend spoke about that in detail. A key message from the APPG is that the Government need to urgently examine how they can better support the integration programme, arrest the decline and ensure that people work together. Social workers in health and in local authorities need to work much more closely together.
Integration in mental health services is about bringing the social mode into healthcare settings, where social approaches sometimes struggle to gain acceptance and respect when compared with the medical model. We do not suggest replacing one with the other but, as integration implies, a full marriage of the two models so that the needs of the individual are met in one place. Better still, a properly integrated social model would make sure that treatment and care planning were guided by the person in their own context, rather than fitting them into a pre-existing diagnostic box. Such an approach means greater consideration of the social determinants of mental ill health—factors such as socio-economic background, education, housing and family dynamics. We have heard examples of that throughout the debate.
The APPG report made several recommendations. The new mental health legislation should open with a definition of the social model and the importance of addressing the social determinants of mental illness alongside biological and psychological determinants; it should explicitly name social workers as the key professionals doing the work; Ministers should ensure that the team preparing new mental health legislation also produces guidance on how it is intended to interact with other legislation such as the Mental Capacity Act 2005 and the Equality Act 2010; the CQC should be mandated to provide an annual report to Parliament on the progress of health and social care integration; and social work leadership—this is particularly important—on trust and CCG boards is necessary. I think it is more than necessary; it is essential. They are professional people with a major and specific role and they should be at the table where the decisions are made.
The report also recommended that new mental health legislation must have greater regard to both health and local authority resources. My right hon. Friend the Member for North Durham talked about the lack of resources within the system. CCGs should be held transparently accountable for their duties under section 140 of the current Mental Health Act, or any new legislation, making sure that there are enough beds in the right places. The people detained under section 3 of the Mental Health Act should be reviewed by a social worker, and families and carers of all people detained away from home because of a lack of local provision should be provided with financial support. That point was raised by my hon. Friend Kerry McCarthy, who talked about the effect that it can have on families when a family member in crisis is 150 miles or more away. A national dataset on the number of Mental Health Act assessments should be established as part of the DHSC mental health services dataset. Those recommendations are not unreasonable. I hope that the Department for Health and Social Care will take note and address the gaps where professionals say that they are.
I recently had the opportunity to serve on the Bill Committee for the Mental Capacity (Amendment) Bill, and key issues that I and other colleagues raised still need to be looked at. During the passage of that Bill, I was quite surprised to find out that the Bill had not been subjected to any pre-legislative scrutiny, despite its central role of redeveloping the laws of this country for depriving people of their liberty. I said that I thought the Government needed to pause and think again about the implications of the plans that Ministers were putting before us, listen to the countless charities, other organisations and professionals who work with the legislation every day, and come back with a Bill fit for purpose. It should not have been about a basic political argument between the Government and the Opposition. It is about a debate between the law makers and the people, some of whom at a particular time in their life can be subject to some of the most restrictive legislation that we have. Sadly, at that time the Minister did not listen, and the legislation we are left with will need to be reviewed before too long. I feel the same about moving forward with reviewing our legislation in general around mental health, and perhaps putting new legislation to this House, but whatever it is, it needs to reflect wide views.
The legislation that we create or amend affects the most vulnerable in our society, as I have said before, but it should be considered with extra care and attention. I do not think that we did that in the recent Bill Committee, so we must include those who know what they are talking about such as the professionals, the experts and the social workers—those who have worked on the frontline of mental health care and know where the gaps are and how we can ensure that we do better for those who receive care under mental health provision. We must and can do better. I hope that as we move forward, Ministers will listen and get it right.
It is a pleasure to serve under your chairmanship, Mr Hanson, as it was to serve under Ms Buck earlier. I join others in congratulating my hon. Friend Neil Coyle on securing this debate and echo their comments about the moving way in which he opened the debate. He started with his own family experience and then made a very powerful speech. I am sorry that you missed it, Mr Hanson. We heard contributions from Dr Lewis and Johnny Mercer, as well as my right hon. Friend Mr Jones and my hon. Friends the Members for Bristol East (Kerry McCarthy) and for Stockton North (Alex Cunningham). I am sure we all want to thank Sir Simon Wessely and his team for their work in reviewing the Mental Health Act.
The wide range of perspectives in the debate is welcome. It shows how wide-ranging the work is and how it touches on so many different aspects. One thing on which we can all agree is that the current Mental Health Act is not working. It is too often overly restrictive and fails to give people the support they need, as we have heard. Before I discuss the contents of the review, I want to mention why it is so important that we get this right, because being detained under the Mental Health Act, although it is sometimes life-saving, can be immensely damaging if it goes wrong, and we have heard already about how it can go wrong. I, too, am going to talk about a case: the case of Matthew Leahy.
My hon. Friend the Member for Bermondsey and Old Southwark referred to the level of sexual assaults on patients—an appalling record, as reported by the CQC. It should be of deep concern to us that that is happening. Staff also failed to act when Matthew reported, and he had physical injuries that could have been caused by rape, which should have been a major cause of concern. It is also deeply concerning that his care plan was falsified and other paperwork was lost. Although he had a care plan for his first 72 hours in the unit, staff produced a fuller care plan only after he died. That that should have happened when he was apparently under the protection of the state is unacceptable. We must ensure that we know what went wrong in his and other cases of death so that we can act to prevent it from recurring.
There have also been issues with the subsequent investigation. The initial report by the NHS partnership contained inaccuracies about how Matthew’s care had been planned. Across the board, the partnership failed to learn the lessons of Matthew’s death, which compounds the tragedy of that young man taking his own life while he was in the care of the state. As my hon. Friend the Member for Croydon North has said, there should be independent investigations of deaths that occur in mental health hospitals. I know that the Minister has been asked before to set up an inquiry into Matthew Leahy’s death. I ask her to commit to doing so now, so that we can learn the lessons from that tragic event and prevent such a thing from happening again.
Sir Simon’s recommendations will not solve every problem with our in-patient mental health services, but the Opposition believe that they would improve them, and would remove many of the major issues with the Mental Health Act. Although we have a little time, we cannot focus on all 154 of the recommendations. I just want to discuss the principles that he felt should be central to the operation of the Act. My hon. Friend the Member for Bermondsey and Old Southwark outlined those four principles in his opening speech.
The first principle is choice and autonomy. Of course, it should go without saying that, wherever possible, we give people control over what is happening to them. I am glad that the Government have committed to introducing advance choice documents. Those will be central to ensuring that people can exercise choice over what happens to them. We have heard in many of today’s speeches why that is important. I ask the Minister to confirm today, if she can, when those plans will be brought forward. There will be instances when people cannot exercise the choice themselves, so Sir Simon’s proposals for the new nominated person role and increased use of advocates will ensure that in those circumstances people are still able to influence their care.
During the passage of the Mental Capacity Act 2019 there was a great deal of discussion, involving my hon. Friend the Member for Stockton North, about advocacy. We must ensure that local authorities are fully funded to provide those vital services. It would be a travesty if someone were denied a voice because of budget constraints at their local council. Can the Minister tell us whether the Government will provide additional funding for advocacy to ensure that that does not happen?
The second principle is that of least restriction. It seems self-evident that we should try to ensure that people retain as much of their freedom as possible, but we have heard of the number of ways in which that does not happen. It might mean supporting people to enter mental health hospitals voluntarily rather than their being detained, or ending the use of seclusion and segregation and the terrible cases of restraint that we heard about.
The third principle is therapeutic benefit. Again, it should be self-evident that everything done under the Mental Health Act should be clearly aimed at helping the person in question to recover. If it is not, what is the justification for detaining them? My hon. Friend the Member for Bristol East talked about people with autism and learning difficulties in mental health hospitals, and we have to question how often their detention for periods of five years, or five and a half years, helps them at all, and whether any of what happens to them could be talked about as treatment.
Finally, Sir Simon emphasised the importance of treating the person as an individual. In particular, that section of the review focused on the current experiences of young people and people from BAME communities in mental health facilities. We have heard about that in speeches today. My hon. Friend the Member for Bristol East talked about the lack of support for families of children with out-of-area placements. Sir Simon recommends that, while those still exist—my party pledges to do away with them—financial assistance should be available when a young person is admitted to a placement away from their family. We are committed to ending inappropriate out-of-area placements, but my hon. Friend the Member for Bristol East talked about a case where, if a facility was the only one that would be able to provide the care, a parent would choose it. However, that support and financial assistance must be available. It is not right to cut off a young person’s support network when they need it most.
My right hon. Friend the Member for North Durham also talked about why the powers under the Act are being used more with people from BAME communities, and we must focus relentlessly on the facts.
Does my hon. Friend agree that we cannot leave the matter where it is? We need an inquiry into it. Sir Simon calls for more research, but unless we have an inquiry we will not be able to get the policy changes to identify what is, clearly, going wrong.
Indeed, and what my hon. Friend the Member for Croydon North has said, today and in speaking about the Mental Health Units (Use of Force) Act 2018, has helped us to focus on the issue of the number of times when young people—particularly from BAME communities—are subject to the Mental Health Act, segregation and restraint. It is not acceptable. None of those cases is acceptable, but it is totally unacceptable if one group seems to be singled out in society for such measures—particularly tragically in the case of Seni. I applaud my hon. Friend the Member for Croydon North for taking that one case and pushing it through to legislation, and the Minister for supporting it.
All the principles I have outlined are important. It is only by following them that we can ensure that a reformed Mental Health Act will work in the interest of those it is designed to help: people with mental health conditions. Will the Minister confirm whether the Government will accept recommendation 1 of the review, that the four crucial principles be put on the face of the Act? We had a bit of a battle during the passage of the Mental Capacity Act 2019 in getting the Minister to accept that things should be on the face of the Bill, but things such as advocacy are pretty important, and it will not be acceptable if they can be overlooked or treated as a budgetary problem.
Does my hon. Friend agree that one of our particular concerns was the way that the proposals related to young people and the fact that although there appeared to be safeguards that might look after adults, the protection for young people, and provision to give their families the necessary help to support them, was thin?
Indeed, and we did try valiantly to get the Minister to accept amendments, but she would not. There is concern. It is a good thing to include 16 and 17-year-olds in the legislation, but not if there are no safeguards. There are real worries. In many cases that I have looked at, and where I continue to try to support families, parents feel ignored and helpless. They feel that mental health hospitals act without reference to the people who know the young person best.
One area in which Sir Simon did not make recommendations was the definition of a mental disorder. Specifically, he concluded that it was not appropriate for his review to decide whether autistic people should remain within the scope of the Act purely because of their autism. I agree with Sir Simon that that is a complex topic, but we should not let it be an excuse for inaction. Autism is not a mental health condition, but the Mental Health Act treats it as though it is. As a result, there are 1,150 autistic people in in-patient mental health facilities. A proportion of them will have mental health conditions that require treatment, but it should never happen that someone is detained purely because they are autistic or because they present with behaviour that could be challenging. I know of many cases where that is happening.
We all saw the deeply disturbing BBC “Panorama” programme on Whorlton Hall, which revealed the shocking treatment that autistic people were subjected to while detained in mental health hospitals. I am sure we would all agree that that treatment is simply unacceptable, but we must do more to prevent it. The best way of doing that is to ensure that people are not put into in-patient environments unnecessarily. If someone does not have a mental health condition that is being treated, they should not be held under the Mental Health Act. Can the Minister confirm that when the Government bring forward the proposals in the review, they will go further than Sir Simon and commit to ending the outdated practice of treating autism in the same way as mental health conditions?
It is eight months since Sir Simon’s final review was published, although it does not seem like it. He made more than 150 recommendations. We did not expect the Government to respond to all of them straight away, but in eight months they have responded to fewer than a dozen recommendations. The other 140 apparently have to wait for the White Paper. We have heard about more reviews from the new Prime Minister this morning. All we seem to get is more rounds of consultation and more reviews, but Sir Simon consulted widely during the review. His review was informed by the experiences of 988 people, including 467 service users—the inclusion of service users is praiseworthy—and evidence from 75 organisations and 90 professionals working in the field. I hope that that included social workers. I thank my hon. Friend the Member for Stockton North for making such a strong case for the involvement of social workers; I agree with him.
The only reason I can see for further consultation would be if the Government were planning to go further on some of the recommendations than Sir Simon did—for example, in removing autism from the scope of the Act. Can the Minister confirm whether that is the case? If not, can she tell us why she feels that the consultation that Sir Simon carried out is insufficient? Surely it would be better to publish a draft Bill and carry out pre-legislative scrutiny in the normal way than to do what has become known as kicking the can down the road. Six months ago we were promised a new set of guidance on the Mental Capacity Act, but that has not been mentioned at all since then. Those are the things that should be coming forward.
We have also been told that there will be a mental health White Paper to implement the findings of the review—we find ourselves waiting for Green Papers and White Papers. Someone could be forgiven for looking at that and thinking that the Government simply do not care about people waiting for much-needed reforms. I know that the Minister cares, but do her Government care? Can she give us a date for the publication of the Government’s mental health White Paper? It is popular to say a season or the end of the year, but a date is more useful to work with. I realise that it is a time of great uncertainty for Government Ministers—I hope that we will see this Minister in her place in future—but a firm date would help us to hold the Government to account should they let their focus slip.
People with mental health conditions have been let down for too long. The review represents a rare opportunity to make changes that have cross-party support—the consensus in this debate has been encouraging—to a system that does not work properly. I hope that the Minister, and the incoming Government, do not waste this opportunity by delaying it further, which would leave people stuck in a system that is harming, not helping, them.
This is as probably as well informed and good a debate as I have ever had to respond to. I hope I can do justice to all the good points that have been made, because we have covered all the key issues relating to how we better support people will mental ill health.
I associate myself with the comments about the personal speech of Neil Coyle, which he made in such a dignified way that I was incredibly moved by his story. What struck me about the experiences that he detailed was that they were his normal, which brought it into stark relief that we are talking about the real day-to-day lives of human beings. It is incredible to hear what people have to cope with on a daily basis. He reminded us that the 1980s had the best pop music, and I was reminded of the “Karma Chameleon” lyric:
“Every day is like survival”.
When we are talking about people with severe mental ill health, every day is like survival, so I thank him for that.
The hon. Gentleman’s speech covered everything that we need to tackle and I do not disagree with anything he said. Obviously, some of the charges that he levelled at me are challenging and I do not want to duck them. Everybody is impatient that we are perhaps not doing as well as we would like in helping people with mental ill health. I share that impatience, but I will not promise that it can be sorted overnight. We are rolling out a significant increase in services and in the workforce to deliver them, which takes longer than anyone would wish.
I will try to address the points that have been made. It was a great pleasure to hear from Mr Reed and to support him in delivering Seni’s law. In connection with that law, he has reminded us that when deaths happen to people who are detained by the state, we absolutely owe it to their loved ones, and to the person who died, to be open with them. The truth is often anything but, because the associated institutions of the state collude to protect themselves. Other Ministers and I are determined that we are the servants of the people, and those institutions that are there to deliver services for the people should remember that and should engage in a spirit of openness.
I have met Seni’s parents and I could not admire them more for the dignity with which they have borne their experience and the good use that they have put it to. I genuinely feel guilty, however, that we have let them down. Hon. Members will be pleased to know that we have a ministerial board that investigates deaths in custody and what can be learned from them, but I emphasise that we—including colleagues in the Home Office and the Ministry of Justice who, along with me, sit on those boards—are becoming rather concerned that not enough progress has been made. I am glad to be in continued engagement with Inquest, which does a fantastic job advocating on behalf of bereaved families. We need to do more to learn from events when they go wrong.
It is clear from the Minister’s comments that she cares passionately about the issues that we are talking about and for which she has responsibility. A consultation on the serious incident framework started in March 2018 with a promise that the findings would be published in spring 2019. From the temperature today, we know that we are way past spring and into summer, but we still do not have a date for when they will be published. Can the Minister share a date by which we might expect that to happen?
I cannot give the hon. Gentleman a straightforward answer to that question but I will write to him with a commitment. It is very boring, but Brexit has diverted officials in the Department. Obviously, no-deal preparations in the health service are a matter of public concern, so we need to make them, but we still need to get on with business as usual. It is an important issue.
Barbara Keeley mentioned the case of Matthew Leahy. I will go away and reflect on that, but I will give the same message as I gave in response to Seni’s law. Generally, we need to get a proper grip on how we learn from deaths that happen when somebody is in the state’s care, because that is clearly unacceptable. We have coronial reports of all those occasions. People should not be waiting the length of time that they are waiting for inquests. When inquests happen, again, there is usually representation from the various institutions involved and the family can be left feeling very under-represented against a mass of organisations trying to avoid liability. We need to tackle that properly.
We have had those discussions at the ministerial board. My ministerial colleagues in other Departments and I want to get a grip on how we properly hoist in the learnings from coronial reports. I look forward to engaging with hon. Members on that, but I will write to the hon. Lady specifically on the issue of Matthew Leahy. It is worth noting that we are looking at the principles of sexual safety in wards, which is not just about getting rid of mixed-sex wards. People are very vulnerable in those situations and it is all about the care regime.
On mixed-sex wards specifically, I cannot tell my right hon. Friend what the proportion is, but we are ensuring that the guidance on sexual safety on mental health wards is being rolled out. I will write to him specifically on that, if he will indulge me.
An important point is that Matthew Leahy phoned the police to report the rape, but they concluded that it was part of his delusion—that was the reason they gave for not taking action. In the case of Whorlton Hall, the police also did not act on reports of assault, although assault was clearly going on. The Minister needs to take that problem up with the Policing Minister. It is not acceptable that what someone says is ignored if they are autistic or detained under the Mental Health Act 1983, because the level of sexual assault is disturbing, as my hon. Friend Neil Coyle said.
That is an excellent point, and it plays into a general prejudice that people who are in detention are just an inconvenience to be managed. In the context of Sir Simon’s review, the whole ethos that any reform we make should be about empowering patients brings with it obligations to challenge other aspects of the system, not just the care providers. The hon. Lady is right to say that I need to take that up with the Policing Minister, which I will do as part of rolling out our preparations for the White Paper. I understand the hon. Lady’s lack of confidence when I say that the White Paper can be expected before the end of the year, but that is certainly my ambition, notwithstanding the fact that I know she has been waiting rather a long time for another paper that she was promised.
I can reassure the hon. Lady on the extent of the work that Sir Simon has done and the engagement we have had, especially with service users. Rather like the hon. Member for Bermondsey and Old Southwark, those service users shared with us their personal experiences, often reliving significant distress. Given that they have participated and that we have raised their expectations, we would, to be frank, be letting them down if we did not address that. I do not think that would be in any way forgivable, so, as long as it is on my watch, we will be pushing ahead.
As the hon. Member for Bermondsey and Old Southwark said, we are dealing with legislation passed in 1983, so although this appears to be a once-in-a-generation opportunity to reform this legislation, I hope that that is not the case. The situation is probably more symptomatic of the fact that we have not given this matter as much attention as it deserves, but clearly that has changed. The world has changed in terms of how we debate mental health, and that is welcome. Chiming in with the discussion we have had today, I am keen that we take this matter forward with consensus.
I pay tribute to the leadership that Sir Simon has shown in this review. As well as not ducking the controversial aspects of examining the legislation, he has engaged in dialogue and dealt with them in such a way that it is accepted that Members, peers, service users and professionals need to consider them. I am incredibly grateful for what he has done.
We talk more about mental ill health now, but when it comes to severe mental illness—the hon. Member for Bermondsey and Old Southwark spoke about schizophrenia —that is something that reveals incredible prejudice in people. As we have heard, if someone is able to manage their condition, they can live a full and independent life, but the key is being able to manage the condition with the appropriate support. We still have a lot to do in educating the public and society about the real impact of severe mental illness.
There are so many issues, but I will try to address them all in the time I have. Kerry McCarthy asked about out-of-area placements for people with autism and learning disabilities. I must say that this is something that really bothers me. Far too many people remain in institutional care and in out-of-area placements, and nowhere is that more true than in the field of learning disabilities and autism.
It is interesting, once we dig under the issue, to see that we have been very successful in getting people with learning disabilities out of in-patient care and into the community. However, that has been matched by a bigger increase in the number of people with autism finding their way into in-patient care. That tells me—I do not think this will be a surprise to anyone in the Chamber—that we are not doing enough to diagnose autism early enough, and as a consequence we are not equipping people with the skills to be able to live independently.
The ultimate result is that we end up putting people in in-patient care. Quite often, those people are forgotten about and it becomes very expensive to keep them there, so not only are we failing people by not having services for them early enough, but we are adding significant cost to the taxpayer and, frankly, doing harm, because the longer those people stay in in-patient care, the more their ability to live independently diminishes. As far as I am concerned, that is a major failing that we need to address.
I thank the Minister for that. There are two aspects that I have come across. First, it is often when a child reaches their teenage years, which we know are difficult for any child with all the turmoil that is going on physically and mentally, that the anxiety takes over and they eventually go into crisis, and things that perhaps should have been picked up sooner are only picked up then. Secondly, that seems to be particularly true for girls. We know that it is more difficult to diagnose girls with autism than to diagnose boys. I was told yesterday, although I do not know whether this figure is true, that one in four girls in mental health units with anorexia is diagnosed with autism. There is a lot of work to be done in the early years, before they reach that crisis point in their teens.
I agree with every word that the hon. Lady says. One of our expectations of the new mental health support teams that we are rolling out into schools is that they will be able to work with schools and to spot people who might be in trouble. She is right that, with girls particularly, autism is under-diagnosed, and by the time the challenges start to have an impact on mental health, it is much more difficult to give people appropriate support. Early diagnosis is key.
I am pleased that we are now setting up a unit within the Department of Health and Social Care to look at neurodiverse conditions and what more we can do to improve service provision for them. I am also pleased that NHS England shares my concern about this and that we can expect more work on it, but there remains a lot to do and I do not shirk from admitting that.
There is also the financial difficulty that my hon. Friend Kerry McCarthy referred to. Private hospitals that autistic people and people with learning disabilities end up in tend to be very expensive—we know that the placements can be as much as £730,000 a year. The answer is to fund placements in the community. Years ago, when we were moving people out of long-stay mental health institutions, there was a dowry system. The Government do not have a dowry system to help with this, so Transforming Care failed because there was no mechanism to transfer funding from the NHS, which is taking the hit on cost, to cash-strapped local authorities. If local authorities are to continue being cash-strapped, and I hope they are not, some mechanism is needed there. My party has pledged to put in £350 million a year of transfers to make that happen. Does that idea recommend itself to the Minister? I know she is bothered about this.
I partly agree with the hon. Lady. The answer is better help within the community, but I come back to the point that Mr Jones made so well. It should not be about beds or in-patient care. The fact that we still have that, and that it is increasing, is a mark of failure. I do not think it should be addressed by reinvestment in in-patient care in the community. The key is putting the support in earlier, and that is what we must aim toward.
The hon. Lady mentions that many of the providers are private, and she is right. One of the challenges I am setting NHS providers is how we can be more innovative, co-commissioning with local authorities to ensure that we have more supported accommodation available in the community, recognising that there will be a saving across the system. I am very clear; I will take it on the chin that local authorities have had more financial challenges than the NHS has as we have tackled public spending, but ultimately, we must think about that person and ensuring that they have holistic care. Silo-based decision making is not doing the people who need our help any good. That is still a work in progress.
Alex Cunningham is right about the role of social workers here. I have regularly debated with hon. Members about the workforce challenges that we face in delivering improved mental health services. NHS England is very clear that that will be developed only through new multidisciplinary models of care, in which social workers will play a part. We can also make much better use of people with lived experience in delivering care for people with mental ill health, not least because engaging with mental health professionals can be very intimidating and threatening, particularly for somebody going through a crisis, and someone with lived experience can bring a very different perspective to that relationship. Much more can be done about that. That underlines the point that hon. Members made a number of times about the need for appropriate support services.
I wonder whether I can prise from the Minister a commitment to look at the fact that there has been a deterioration in the number of authorities that are working with our health partners. Integration is deteriorating, rather than increasing. The model must be better, and all professionals must work together.
That is a fair challenge. We certainly will. One of the difficulties when there is a financial challenge arrangement is that people retreat into their silos and say, “This bill is your problem.” That is not good enough. We have to be better at challenging them when that happens.
I am very clear that commissioners need to be much more imaginative. There is often a tendency to over-medicalise some of these issues. We have heard today that wrap-around services can be delivered much better by the voluntary sector, with better value for money and in a less intimidating way. That can often be more reliable than relying on in-NHS services.
There are two aspects to homelessness. It can often be symptomatic of a mental health issue or addiction; it is symptomatic of the fact that the person needs help. Equally, it exacerbates the issues that those people have. We have made resource available to tackle the holistic needs of rough sleepers, but again we are treating the problem at the crisis end. People struggling with their housing situation will be more likely to need help, so we need to look at what else we can do to support people at that stage.
I was challenged on when we will end the use of police cells to detain people under the Mental Health Act. I want that to be written on the face of the Act, so that there is a clear binding commitment to do that. We have reduced it by 95% so far with places of safety, so I am confident in saying that detention in a police cell is a rarity these days; nevertheless, we need to guarantee that.
On in-patient care and out-of-area placements, it is clear that people recover more quickly if they are closer to their family and friends. As the hon. Member for Bristol East said, there is sometimes a need for specialist support. We need to look at how that interaction happens with NHS England. Specialised commissioning and delivering a very narrow service will inevitably lead to out-of-area placements, but are we doing more harm than good? Should the best be the enemy of the good? NHS England commissions a quantum; it does not scrutinise individual commissioning decisions. That is more likely to happen if it takes place locally. That is still work in progress.
I cannot commit to delivering that, but I can commit to looking at it. I hope that is good enough for the hon. Gentleman.
In the case that I was talking about, the problem was not just that the treatment was so specialised that it was that far away, but that that was when the bed became available. It is a bit of a lottery. The one closest to home was not taking in new patients because it was in special measures. There would have been other places closer. If the person does not accept a bed when one becomes available, they may have to look after a distressed child for an awful lot longer.
This comes back to housing. One challenge is getting access to a bed, and another is when the person comes to leave, because we need to discharge people into safe living environments. Are there enough supported housing solutions? No, not always, so the bed remains full. I am having conversations with colleagues in local government to see what more we can do to deliver more supported housing so we can get the pathway going. We could fix it by making more beds available, but that is not really the answer. I am concerned that the longer we leave people in in-patient care, the more harm we do. We have to get that movement through the system. Hopefully, if we do that, people will be less likely to grab the first bed because they can be confident that more will become available more frequently. That is where we need to get to. I appreciate that right now it feels desperate.
There is an issue with quality. The Care Quality Commission has a challenge in deciding whether more harm will be done by taking enforcement action on a place rather than working with it to improve. We see that writ large in TV programmes such as “Panorama”. There is a massive disparity in the quality of care. I challenge the CQC to be a lot more aggressive when we see poor standards of care.
The hon. Member for Bristol East mentioned private providers. People have heard of The Priory. They hear that celebrities go there and they think it is a centre of excellence. The truth is that the care there is less than optimal, but someone with a loved one who needs hospital treatment will not know that. We need the CQC to have a lot more teeth in terms of improving what comes out of its inspections. The system generally needs to support it in doing that.
I am grateful to the Minister for giving me another opportunity to ask a question. While she is on housing, there is a growing issue of vulnerable young people and looked-after children being placed in unregulated, semi-supported homes or hostels. Some of them have severe mental ill health. When they are placed in such settings, they do not receive the support they require and become a danger to other people residing there. That happened in the awful case of Lance Scott Walker, a looked-after teenager in the care of Islington Council. He was placed in a hostel in Ealing, where he was stabbed to death by another young person with schizophrenia. It is clearly inappropriate for young people to be put in those kinds of setting. Is the Minister intervening with local authorities and the Department to try to prevent a repetition of that case?
I thank the hon. Gentleman for sharing that case. I was not aware of it. Some local authorities are not as good as they should be in discharging their responsibilities as corporate parents. It is clearly their duty to ensure that looked-after children are housed in an appropriate setting. That issue lies outside my purview, but I will take it up with colleagues in the Department for Education to ensure that we are properly enforcing our obligations towards looked-after children in relation to housing. That is clearly a concern to us.
Gosh—I have so much to get on to. The hon. Member for Bermondsey and Old Southwark talked in particular about Southwark and rightly challenged me by saying that seeing perhaps only 35% of children was not enough. I agree, but I have been really impressed by the efforts made by Southwark on mental health support for the school population. It illustrates the importance of good leadership and working collaboratively with other organisations. I was pleased to visit Charles Dickens Primary School—I do not know whether it is in his constituency.
It is a fantastic school. It was amazing how the principle of mental wellbeing ran through the whole school from walking in to the point where the kids pick up a sticker that reflects their mood and put it on the whiteboard, so straightaway the teacher could look out for those who were feeling a bit distressed. The other amazing thing was the teaching assistants, who instead of being based in each classroom all had specialisms and did lots of one-to-one activities outside the classroom. Even more importantly, there was a facility to reach out to parents pre-birth—obviously families tend to go and see schools. I was hugely impressed, and that goes to show how we should be encouraging innovation and imagination with regards to these services. In fact, it is probably the poster organisation to show that mental health is not everybody else’s problem; it is all our problem. The ability for such engagement in school is fantastic, so well done Charles Dickens Primary School.
Members will be pleased to know that Sir Simon Wessely has worked with the sector, and interest groups in the sector, in coming up with his proposals. I am also in regular dialogue with them to discuss the principles. In the spirit with which we all approach reform of the Mental Health Act, we obviously want to keep people safe, so there needs to be the power for potential detention, but most importantly we need to protect the rights of patients and empower them. That is the principle that I really want to underline.
We have moved past the point of discussing people with autism and learning disabilities. I take on board the Minister’s concern, but I wonder whether she could answer my question. Under a reformed Mental Health Act, is she looking at—or minded to look at—changing how people with autism are included as if they have a mental health condition? That is important to a lot of people, and Sir Simon did not rule on it.
We need to look at issues about autism in the round. The hon. Lady is right that it is currently treated as a mental health issue for the reasons outlined by the hon. Member for Bristol East: it is not diagnosed until a mental health issue materialises. That is really the issue. I would like us to use the 10th anniversary of the Autism Act 2009 to reboot our approach to ensuring that we are looking out for people with autism. In a way, we must go through the same journey with autism and learning disabilities as we have with mental health. That does not really answer the question from the hon. Member for Worsley and Eccles South.
As far as legislation is concerned, ultimately people with autism who are suffering from mental ill health will be detained under the Mental Health Act. Perhaps we ought to pick up how that interacts with other legislation as we develop the White Paper. The overlap is a clear problem.
I have paid tribute to Sir Simon Wessely. We are all about making sure that our reforms deliver genuinely person-centred care. We should be removing coercion and control as far as we can.
My hon. Friend Johnny Mercer talked about Georgi Lopez, who addressed the all-party group and whom I had the pleasure of meeting. She tells a compelling story about her contrasting experiences. She readily concedes that on one occasion being detained under the Act was the best thing that could have happened to her, but on another occasion it did her genuine harm. In fact, Members who read Frank Bruno’s book will find exactly the same story. It is almost as if once someone is on that pathway and under detention, they will always be seen through that prism. We need to tackle the underlying prejudice. People who are suffering from mental ill health are vulnerable; they are not an inconvenience. Any services provided by the state need to be working with them to support them, not to do them harm.
Our overall objective when we asked Sir Simon to look at the Act was to reduce the rising number of people detained under it. I hope that underlines the spirit with which we are approaching the inquiry. We also asked him specifically to address the disparities in how the Act is used, highlighting in particular the impact on black and ethnic minority groups, but also on women. It is of great credit to him that he went much further than that and led a full review of the entire Act. Again, that raises the expectations on me to deliver fundamental reform—but that is fine; it is what I am here to do. He did so with such speed, and having taken so many with him, that he has provided exactly the right conditions to approach reform.
Sir Simon built relationships with service users and carers, and I am riding on the back of them. I meet those people regularly to hear directly from them about their responses to his recommendations. We will continue with that. I have been struck by some of the experiences shared with me by service users and family members, which bring home how disempowering it can be. I often talk about the arrogance of medical professionals who, when someone turns up and says, “Fix me,” send them along. That dismissiveness can be more so in mental health than anywhere else. We need to ensure that we put in a regime that treats people with dignity and respect.
At the heart of this issue, the current Act has much too big a disempowering effect, which does too much to remove people’s autonomy and not enough to support their decision making and influence over their own care. It is dehumanising. We should look at detention as the last resort, because it does genuinely do harm. That is not to be critical: staff will act with the best of intentions, but a lot of it depends on culture. When Georgi Lopez shared her experiences, she talked about the two very different cultures of the organisations in which she was detained. When the CQC visits such places and assesses whether they are well led, it must assess the culture and whether patients are genuinely empowered.
I do not think we should duck the fact that sometimes we will have to detain people for their safety and that of others, but we need to ensure that we have the right guarantees in place. I am struck by something that Sir Simon always says: from the moment of detention, release planning should start there and then. A credible care plan is all about getting people back out and re-empowered. It should be based on consent and empowering the patient.
As has been mentioned, Sir Simon’s report contains 154 recommendations. I will work with the Ministry of Justice on a joint White Paper from both Departments, which will come forward by the end of the year. We have already started to implement the recommendations that we can, and I hope that Members are reassured by how, last week, the previous Prime Minister re-emphasised her commitment to making sure that we tackle the issues regarding black and ethnic minority detainees. I know she will continue to have a full interest in these issues from the Back Benches. I reassure the hon. Member for Worsley and Eccles South that if she sees no sign of a White Paper, she has a good ally on the Government Benches to hold the Government’s feet to the fire. I look forward to engaging with all hon. Members on those recommendations when we come forward with our White Paper, for which we should also consider the issues that have been highlighted during the debate.
As I have said, we want to modernise and ensure that people who are detained under the Act receive better care by improving patient choice and autonomy in their treatment. We will introduce statutory advanced choice documents to enable people to express, in advance of detention, their view on the care and treatment that works best for them.
It is important to talk about the role of family, because we have agreed that patients should be able to identify a nominated person who will have the power to look after their interests under the Act. At the moment, the next of kin is the default. I have heard compelling evidence from patients who have said that that is not always appropriate. Family members can often be a source of abuse or additional pressure and harm, so patients want to be able to nominate someone, which seems extremely sensible. I recognise that that will cause some controversy.
The Minister says that that seems extremely sensible but if, for example, somebody is seriously mentally ill and imagines that their parents mean them harm when they are actually doing everything they can in support, should the parents be locked out from knowing what is happening to their child?
We will have to have that debate. My right hon. Friend articulates the opposing position to what I have heard. I regularly hear his example when I chair the national suicide prevention panel. We have had dialogue with NHS organisations and there is a consensus statement setting out the framework by which reports can be given to family members. Equally, patients who are detained under the Act should be able to say which family members should not be consulted about their treatment. For example, we see women who are victims of domestic violence and abuse by their partner and find themselves detained under the Act; their partner would normally be their next of kin, but it would not do those women any good for that person to be contacted.
I quite agree, but my debate was nearly nine years ago. Is it not a bit late in the day for the Government to say, “Well, we are having a conversation about this?” At the time, there seemed to be some quite sensible rules, but the main problem was that the local mental health authorities were not applying them. If anything, it seems that we are further away from our objectives than we were nine years ago.
I think my right hon. Friend misunderstands me. We have a consensus statement that governs how NHS organisations and practitioners should deal with people at risk of suicidality, although there is concern among bereaved families that it is not always followed. Equally, in delivering a service that empowers patients, those patients should be able to identify their nominated person. Those discussions take place much more frequently when people set up new relationships with NHS practitioners. When they change GP, for example, they are invited to nominate a person, in case there are any safeguarding issues.
I hesitate to intervene one last time. I fully accept the Minister’s point about abusive partners, but what if the person is desperately, seriously ill and delusional, and the mother is not allowed to be told information about their offspring, because they are technically an adult? At what point do you decide that the person has lost capacity to identify correctly with whom information should or should not be shared?
That highlights the importance of having a nominated person earlier in the journey. I do not disagree with my right hon. Friend, but he highlights the difficulty of our work to get the balance right between keeping someone safe and respecting their wishes. I fully anticipate that when we produce the White Paper on this issue, he and I will probably have another debate about it. It is important that we get it right, with the safety of the patient in mind while empowering them to make their own decisions.
I have already mentioned that we will end police stations being places of safety under the Act, and that will be included in any legislation. On equalities, we are working with the NHS to introduce the first ever race equality framework to ensure that mental health care providers work with local communities to improve the ways that patients access and experience treatment. An important point is that although we are concerned that under the Act there are far too many detentions of people from black and minority ethnic communities, it is possible that is partly because they find it difficult to access services. We need to address that properly.
To help to address that, we are also launching a pilot programme of culturally appropriate advocacy. Clearly, we will need to make that resource available to ensure that people have access to it. The review said that we need to learn a lot more about that whole issue, so we will work with the National Institute for Health Research, which will launch a call for research later in the year to give us more answers. Jacqui Dyer MBE is our Mental Health Equalities Champion, and she will play a leading role in taking forward the review’s recommendations on tackling the injustices faced by black and minority ethnic services users.
I have spoken for quite some time; I hope I have covered most of the aspects mentioned. On the issue of funding, I have probably bored everyone senseless by saying that we are determined to deliver a much-expanded service, and our focus must be on developing those community services. We have made resources available to do exactly that through the long-term plan, but that is not to say that the issue is not still challenging. However, I hope we will be able to do much more in the community for people with severe mental illness, so that we can treat them in the community rather than have them go into crisis care.
To illustrate that with an example, if we can get people out of beds and into the community, the ability to look after more patients is really stark, so it starts to pay for itself. I discussed that with a clinical director from the NHS, who said that if they remove three people from in-patient beds and have them in the community, the productivity is so much greater straightaway. We rely on good local leadership to crack that and make it happen.
I have covered most of the things I wanted to. I will just reiterate my thanks to all Members who have participated in a very good debate, and I look forward to having discussions on the White Paper as it develops.
I thank all colleagues for their comments and personal experience. When I worked at the National Centre for Independent Living, the charity ran Experts by Experience across social care. I hope that the Minister takes note of that—it sounds as if she is talking about involving survivors, service users and carers in future plans. I thank the Minister for her frank admission that we need to do more. Again, I thank all the organisations involved.
Some people are commenting online that too few of us are here in the Chamber, but lots of work goes on outside such debates as this one. For example, my hon. Friend Alex Cunningham and my right hon. Friend Mr Jones referred to the all-party group on social work. Johnny Mercer also works on mental health outside that group, and reference was made to the previous legislation of my hon. Friend Mr Reed.
I asked the Minister 10 things, I think, most of which were covered in her response, but I will follow up on some. On children’s access to mental health care, it is great to acknowledge the leadership of Charles Dickens Primary School in Southwark, but that 35% target is a national one, and it would be good to know from the Minister what more is coming in the system. On the principles in the independent review, she mentioned gratefulness, an indication about the principles, and she just touched on the advocacy issue. It is important to note that the piloting of the culturally appropriate advocacy is more limited in scope than the review intended, so it needs to be expanded to everyone, whether informally through in-patient care or to people detained. The model should be an opt-out one, which was the preference of the review.
The Minister confirmed that the White Paper will still be on time. My right hon. Friend the Member for North Durham talked about when legislation might appear, and perhaps the Minister will indicate that in correspondence. She touched on resources, the need to expand the service offer and how it pays for itself—how she is making the case for parity of resource allocation in the system would be good to know. She spoke positively about the nominated person and better involvement of nearest relatives, and that is really welcome. That person is of course chosen when someone is well—that is the key difference. No matter how ill someone becomes later on, or how badly they suffer delusions, the person whom the patient chose when well is important.
Earlier upstream interventions were mentioned by my hon. Friends the Members for Bristol East (Kerry McCarthy) and for Oldham East and Saddleworth (Debbie Abrahams), and others. The Minister commented that the high level of detention through not getting that right was a mark of failure. The spirit of the plans is to get that level down. It would be good to see more.
It was brilliant to hear about the custody cells, which will be included in any legislation. That is a brilliant commitment. On sexual assaults, I think that the response was that we need to learn more. I welcome the earlier campaign of Dr Lewis to end mixed-sex wards, but such incidents are still occurring. More needs to be done, just as it does on the issue of deaths. There was a specific request for an inquiry, and it would be good to know the Minister’s view of that.
On standardised support and care, my hon. Friend the Member for Bristol East told us about the family of a child with autism having to make that decision on whether to travel. The Minister said that too many are in that position, and it is something that the CQC should look at. Given that the CQC may only gain the powers and resources that she mentioned through Government, I think a stronger case needs to be made for that.
On advance decisions, there were some positive comments but I will come to an end. The lyrics of “Karma Chameleon” were mentioned by the Minister, and Prime Ministers might “come and go”, but the people who need their lives transformed and who need better mental health care experience the outdated legislation every day. I hope that after the White Paper we will see real pace to deliver reform.
Question put and agreed to.
That this House
has considered reform of the Mental Health Act 1983.