Mental Health Act 1983

Baroness Watkins of Tavistock Excerpts

Tuesday 21st November 2023 Lords Chamber

[Lord Markham (Con)]

Yes. I have tried to get into this further, and my understanding is that lot of the trouble is that there is often a fear from black and ethnic-minority people of the existing institutions that can help people early on. As we all know, with mental health difficulties, we have to act quickly. A lot of this is about getting everyone in society open to the idea that the earlier they can go to these sorts of places, instead of trying to brave their way through, the better. That is one of the key things to do to make sure that we do not then see problems down the pipeline, including the disparity whereby a black person is 11 times more likely to have community reviews and the disparity in detentions.

[Baroness Watkins of Tavistock (CB)]

My Lords, I think that other noble Lords will welcome the idea of sitting down at a round table to look at the future. In particular, what do the Government intend to do to invest in children’s and adolescents’ mental health services to make them accessible in schools? Early intervention will prevent a high proportion of people needing to be sectioned later on.

[Lord Markham (Con)]

The noble Baroness is absolutely correct. With the mental health units to detect problems early, we are now at around 35%; last year it was only 25% but in the next 18 months or so we should be at 50%, which is higher than ever before. I freely accept that 50% is not 100% but it is clearly a step in the right direction. The £2.3 billion investment we are putting in means 350,000 extra places for young people as well.

King’s Speech

Baroness Watkins of Tavistock Excerpts

Thursday 9th November 2023 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, it is a pleasure to contribute to this debate on the King’s gracious Speech, and to acknowledge His Majesty’s Government’s commitments for this Session. I declare my interests as chair of Look Ahead, a housing association that supports homeless people, and as a non-executive director at NHS England.

First, I turn to education. The Children’s Commissioner emphasises that school attendance is an absolute priority if children are to be offered the best start to further their ambitions, relationships and learning when in school. However, current data demonstrates that, since schools have reopened after the pandemic, one in five children remains persistently absent, on average missing at least one day in school a fortnight or 1/10th of the academic year. This means that 1.8 million children are regularly missing education.

It is suggested that the social contract between schools and parents had been broken following the lengthy period of school closure and that many children are waiting for mental health support and education, health and care plans. The wait is reportedly two years in some situations. So, while I support the Government’s intention to introduce a register of children not in school, can the Minister explain how this information will be used to support those children and their families to increase school attendance? Will there be a national or local authority register of waiting times for assessment for education, health and care plans, with clear targets for achievement in the way that there is, for example, for NHS cancer targets? We know that the future health and happiness of those children regularly missing school are severely impacted if mental health intervention and tailored educational support are not available within—shall we say, conservatively—six months of regular absence.

Secondly, what early years entitlement will be made available for younger children? The Early Education and Childcare Coalition reports that only 17% of nursery managers say that they are likely to increase the number of places they provide due to the difficulty in recruiting staff. Can the Minister say whether it is the Government’s intention to re-establish a career development hub at the Department for Education for a national apprenticeship scheme in early years education that will encourage not only women but men into this important area of work? There is probably a need to restart the graduate-led grant scheme.

The King’s Speech was deeply disappointing in having no reference to reforming the Mental Health Act 1983. Others have spoken about this, but in 1983 I was a junior lecturer introducing the changes to staff in the Lambeth health authority. I distinctly remember a slide that said, “This is a really interesting review, but remember that it is only a review of the 1959 Act, and we will have a proper, new Mental Health Act soon”. That was 40 years ago. There was a manifesto commitment in both 2017 and 2019 to reform this. It seems to me that this particular revision has been on a waiting list for a minimum of 40 years. Yet over 53,000 people were detained under the Mental Health Act in 2021-22, many, of course, for appropriate assessment, support and treatment.

However, significant disparity between ethnic diversity and detention under the Act continues, with white people five times less likely to be detained than those from different racial communities. Does the Minister agree that, while reforming the Act is long overdue, that should not stop us enhancing patients’ rights and strengthening safeguards for those admitted to hospital much sooner than an Act might come? I believe it is essential that we find sufficient resources to ensure that we can deliver high-quality, compassionate care—which is often in the community—before we review the Mental Health Act, if we are not to get it in this Session.

We know that many people with significant mental health needs are in prison, when many would be far better served by proper community support and treatment in safe, secure housing—particularly before they offend. Sometimes, individuals who have significant mental health challenges offend because they are homeless and have difficulty in claiming benefits and accessing the healthcare system.

I acknowledge other noble Lords’ contributions to this debate on the proposed reforms associated with housing, leasehold and renters; I will leave it to others to speak on that. I hope that this will result in fairer systems, but it will not result in a significant increase in social housing, which is completely vital to improve healthcare in this country.

Finally, I welcome the Government’s commitment to supporting the NHS workforce plan and hope that, in the longer term, this will have a positive effect on current waiting lists, which are in part due to a shortage of qualified staff as well as the Covid pandemic. However, I was concerned to hear the Minister say that he believes that the pandemic was a once-in-a-generation situation; I only hope that he is right, because we need to be ready in case we get a second wave. Do not let us be complacent; we need the right social care to support people if that happens.

I commend the proposals relating to tobacco and vapes. As many noble Lords know, my concern about the use of alcohol by young people remains, and I wish that there had been something about that too in the Speech.

Suicide Prevention Strategy

Baroness Watkins of Tavistock Excerpts

Thursday 26th October 2023 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister assure us that DWP staff are being trained properly in recognising the suicide risk of such claimants? One of the most important things is that people largely want to work and getting rejected following job interviews is a huge risk for that particular population.

[Lord Markham (Con)]

Absolutely. It is my understanding that all front-line DWP staff have two days of mental health training in precisely this area. Also, their stated objective is to support people in what they can do and support them into work based on their abilities. We all know that work gives people a big feeling of self-worth and confidence and is a key to both physical and mental health.

NHS Long-term Workforce Plan

Baroness Watkins of Tavistock Excerpts

Tuesday 4th July 2023 Lords Chamber

[Lord Markham (Con)]

I thank the noble Lord. He is quite right to say that we need to check against delivery and he is quite right to hold us to account on that. Personally, I am happy to commit whatever time we need to debate this because I completely agree on how important it is. As I say, it is quite sobering when you think about the figures: as we said, we expect one in eight school leavers to go and work in this sector, so we almost cannot spend too much time on that.

As I say, the dental plan will be published shortly, and making sure that the balance is right, and that it is seen as an attractive option to be an NHS dentist versus working in the private sector, is absolutely an important part of that as well.

[Baroness Watkins of Tavistock (CB)]

My Lords, I very much welcome this plan and in particular the fact that we will start to deliver more homegrown healthcare workers; in fact, the WHO has applauded us for these moves because there is such an international shortage, not because overseas workers are not welcome here.

I want to ask one question. I very much support the concept of apprenticeships, but professional workers on registers, be that nursing, medicine, physiotherapy or paramedicine, expect apprenticeships to be degree-level apprenticeships, accepting that the entire workforce will not be graduates but that registered clinicians should be. Can the Minister please clarify that issue?

[Lord Markham (Con)]

I thank the noble Baroness. The whole idea of the apprenticeship is that the standard that you are training to is absolutely the same, albeit obviously you are getting there via a different route. However, as regards the capability, training and knowledge of that person, clearly, whichever route they have come from, they need to be at that same required level. That is why the royal colleges have been such an important part in the development of this whole plan.

Mental Health In-patient Services: Improving Safety

Baroness Watkins of Tavistock Excerpts

Monday 3rd July 2023 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I welcome the Statement, but I will raise two issues. First, it seems that several different bodies will look at what the problem is, yet the ombudsman has just said that it is absolutely imperative that

“The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like”.


Could the Minister comment on how that will be considered in tandem with the proposals outlined in the Statement?

Secondly, will the proposals look at a safe staffing model for all in-patient mental health services? In fact, in-patient services are really looking after only those people who have severe mental health problems; they are almost the equivalent of an intensive care unit in a general hospital. Increasingly, staff do not have time for proper continuity of handover when they leave shifts, and that needs to be examined. It is relatively easy to describe somebody’s blood pressure and blood stats in an intensive care unit as you hand over in a general area, but to describe the complexities you have been working with, for example with somebody who has severe schizophrenia and is deluded and paranoid, takes a good 10 minutes in a handover. I would welcome the Minister’s comments on how we will look at ensuring that that is considered when measuring safe staffing.

[Lord Markham (Con)]

I thank the noble Baroness. The points she rightly makes are exactly what we believe is the remit of the new HSSIB review starting from October. One of the specific points is about developing safe therapeutic staffing models for all mental health in-patient services. I think and hope that the exact points raised by the noble Baroness will be addressed by the review.

Dementia Palliative Care Teams

Baroness Watkins of Tavistock Excerpts

Thursday 15th June 2023 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I draw noble Lords’ attention to the recent research report from King’s College London about better palliative care and end-of-life care for those affected by dementia. It shows clearly the cost-effectiveness that can be achieved and the reduction in the use of in-patient hospital beds. I declare that I am on the NHS Executive and am pushing for this. What can the Government do to ensure that ICBs actually take this forward?

[Lord Markham (Con)]

As I said, we think that the ICBs are the right place to manage this at a local level, but it is our responsibility from the centre to make sure they are delivering on that. I personally have seen good examples: my father was cared for at home, with palliative end-of-life care, and I know how happy he was to be able to do that, so I totally agree.

NHS National Health Inequalities Improvement Programme

Baroness Watkins of Tavistock Excerpts

Thursday 25th May 2023 Lords Chamber

[Lord Markham (Con)]

As mentioned previously, the review did not happen because of Covid, and it is very much within the plans that it is time to look at school standards again. Clearly, that is key to making sure that there is a healthy diet in schools, and of course that goes across the board.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister explain whether the Department of Health is working with other departments to consider funding families entitled to free school meals with additional allowances during the summer vacation in the light of the current cost of food and the need, as he has acknowledged, to provide adequate nutrition to promote health in young people?

[Lord Markham (Con)]

Yes. It is worth reiterating that the 37.5% free school meal level is an achievement, as is the fact that all infant schoolchildren receive free school meals—higher than ever before. However, the noble Baroness is correct in terms of what happens during holidays. That is why we have the holiday activity fund, which in the summer holidays, for instance, provides meals for four of the weeks, as well as for another week in winter. Clearly, we need to keep that under review to make sure that that is sufficient.

Health Education England (Transfer of Functions, Abolition and Transitional Provisions) Regulations 2023

Baroness Watkins of Tavistock Excerpts

Tuesday 21st March 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, I very much appreciate the opportunity that the noble Baroness, Lady Merron, has given to the House to debate this reorganisation on the back of her regret amendment. In preparation for this, I had a look at Health Education England’s website; it is always good to look at the thing you are abolishing. It is worth quoting in full what it says about itself:

“Health Education England … exists for one reason only: to support the delivery of excellent healthcare and health improvement to the patients and public of England by ensuring that the workforce of today and tomorrow has the right numbers, skills, values and behaviours, at the right time and in the right place.”


That would perhaps be an appropriate motto for the Minister to have. It is timeless: we want people to be focused on that mission of delivering the right people with the right skills at the right time and in the right place.

Again, I looked at the history of the body. It was set up as a special health authority in 2012. I imagined that it was something we had had for years, but no, it was set up in 2012 and became a non-departmental body in 2014. So in about a decade we have gone from wanting a body with a singular focused mission to saying, “No, that’s a disaster; it needs to now be fully integrated into a much bigger body in order to be able to deliver”. I fear we have seen this again and again; we had it with NHS Digital. A group of people got together a decade or so ago and said that the important thing is that all these functions have a team that is solely dedicated to delivering workforce, digital or whatever, and 10 years later the fashion has changed. The Minister makes a reasonable argument that you would not now have a separate HR function. Clearly, a decade ago, we thought that was exactly what we should do, and we spent time and money constructing this thing. Now we are spending time and money destructing it.

There is a risk that we end up mistaking circular motion for forward motion. It is still motion—we are moving things around—but there is a risk that we are not making progress. I will explain why we need to have really serious measures to understand whether we are doing that; otherwise, I fear we will back here in five or 10 years’ time, with people standing at the Dispatch Box arguing why we need to separate all these functions out, because merging them into NHS England meant that we lost focus.

The one group of people that will continue to make money out of this is the consultants. I note we are told in the Explanatory Memorandum that they were paid £1 million plus VAT to create this reorganisation. I am sure a similar group was paid £1 million plus VAT to spin out HEE when it was originally set up, and we will see this again with all the different parts of the health service. We spend money and we reorganise. Even if we support the latest organisation, we in this House need to continue to hold the Government’s feet to the fire, whoever they are, to say, “Prove that the reorganisation was worth the money”.

The noble Baroness, Lady Merron, is quite right to keep bringing us back to the information in the Explanatory Memorandum and the reports we get from the scrutiny committee. We are given explicit information about the costs. We are told that it is £1 million plus VAT for the consultants and another £1 million for staff costs, so a couple of million pounds here and there for direct costs. The savings are much less clear. We are told they are £1.3 million because we no longer need a separate board; then the big savings are wrapped up in this aspirational 40% for all of these reorgs into NHS England, but we are not given any more detail than that. I know the current body of staff in Health Education England is some 2,000 people, overseeing approximately £5 billion of expenditure, so there is clearly a lot of scope for potential savings.

I ask the Minister to make a firm commitment that the Government will come back and that future NHS England reports will give the kind of detail we need in order to understand whether those savings were realised. When these reorgs happen, there is a risk that NHS England’s future reports will be structured in a way that disguises the savings so that we cannot pull them out. It would help the House and the public if, when NHS England reports in a year’s time, there is a separate item that says, “For NHS Digital, we did or did not realise these savings”, and, for Health Education England and the education functions, “This is how many staff we now have working on it and that is why we think we are getting better value for money from the budget”.

From an accountancy point of view, you can go either way: you can either try to hide things by smushing them all up together or try to make them explicit by ensuring that the data is there. I hope that the Minister will commit so that we can come back at this time of year in 2024, 2025 and 2026—I recognise that this will take time to play out—to see whether this reorganisation has had the effect. This would inform the debate next time we are asked to reorganise; I am sure we will be told every time that they will make savings.

Finally, the substantive point raised by the noble Baroness, Lady Merron, is around the workforce plan. We can repeat our previous exhortations: that this is desperately needed; I know the Minister agrees that it is desperately needed. There are concerns that the reason it is being held up is that the funding is not there. Every time we see good news—the pay settlement for nurses and others is good news—a little bit of us asks where they will find the money; we hope they will not find the money by cutting in other areas. We need continual reassurance that the workforce plan will be accompanied by the money that will be needed to deliver it, and that we will not see it shaved away as it goes through the process of finalisation. That might be partly why we want it quickly. Once it is published, it is much harder to step back. The fear is that, the longer it takes, the more likely it is that there will be a process of salami slicing and the bold, ambitious workforce plan, which I am sure the Minister and his colleagues in the department supported, ends up “Treasury-fied” and no longer quite as ambitious as it was.

Finally on the workforce plan, we are talking about the NHS and we are rolling Health Education England into NHS England. As we have discussed many times in this House, health and social care are intimately related in terms of being able to deliver for people out there and being able to run an efficient service. I hope the Minister will at least be able to say that this reorganisation will not negatively impact joined-up workforce planning across both sectors. Ideally, I hope he will be able to say that there will be some positive impact from this reorganisation in terms of making sure that social care staff numbers correspond with the increase in NHS staff that he knows we need.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interest as a relatively new non-executive director of NHS England, appointed together with two expert doctors to give clinical input to the board and tackle the issues that have just been discussed. However, I want to put on record that I think Health Education England has been a success and has set up sound processes that have enabled a good estimation of the workforce needed for the next 15 years.

The workforce plan is in draft and is being considered by the Government, but I want to underline the fact that, without sufficient funding, it will not achieve what everybody wants it to achieve. I believe that making it mainstream in NHS England should mean that, working with the ICBs, we have a sound approach for the future. I am aware that the two previous speakers will be able to hold NHS England to account on whether we get it right or not. I felt that I should be here this afternoon to say that I think it will work, but only because of the sound foundation that NHS Education has left behind.

I also want to echo one concern: that we have to calculate social care needs within the workforce development plan, in particular the needs of leaders of teams in social care, who are often nurses or allied health professionals such as physiotherapists. On that note, I will sit down; I wanted to express my current understanding of the situation.

[Lord Scriven (LD)]

My Lords, I wish to add briefly to the very useful and interesting debate that the noble Baroness, Lady Merron, has stimulated with her amendment. In so doing, I point out my interest as a vice-president of the Local Government Association.

I support the general direction of the merger. I can see why HR functions need to be streamlined together rather than partly devolved and partly in NHS England. The Minister quite rightly pointed out his business background; I have a background in organisational development and public sector reform, not necessarily in the UK but in Africa and south-east Asia. One of the key failures in the public sector when these organisational structures happen, predominantly for cost reduction reasons—it is always said by those leading them that cost reduction is not the reason, but it is important—is that there are no measurements for success in three, five, 10 and 15 years. Without that, you get a structure without understanding how the structure will deliver exactly what is needed.

So, what are the measurements for success in three, five, 10 and 15 years? Without those, everyone can say there is a target, but no one knows what that target, or bull’s-eye, really is. What are the clear measurements within three, five, 10 and 15 years? If they are not there, how do we know what success looks like based on what the merger was about in the first place? That is really important.

The other part of this is that you can have all the training and numbers you like for the workforce, but if the support, conditions and culture are not right, people will leave, as they are doing now in parts of the NHS. In certain specialties, you cannot get a doctor for money, no matter how much you offer. Part of that is about working conditions, culture and support. How does this merger deal not just with numbers and education but more holistically with the culture and support? For example, in many trusts, junior doctors cannot even get a meal in the evening. You can have all the numbers you want in terms of training, but if people decide not to work because of the conditions, how does that help holistically? How do we ensure we have not just the training and numbers but the culture and support within organisations so that people decide to go and work there?

My final question is simple. All noble Lords who have spoken have mentioned social care. As I said, my question is simple: how does this plan link with a plan for the social care workforce? What problems are envisaged and what mitigation has been put in place to ensure, first, that the two plans work in tandem and, eventually, as a long-term aim —I have heard Ministers talk about this—that staff will be able to move across the organisational divide? How will the links be there? What mitigation is being put in against the risks for a social care plan and a healthcare plan? This is important because people who start with a health problem then require social care to make as good and independent a life as possible. It is important that, when the Government start on one plan, they understand the linkage with the other and the mitigations needed. I hope that the Minister can put the mitigations in place.

As I said, in general, I understand the reasons for this but there are serious questions that the Minister needs to answer to ensure the maximum impact from this merger.

Mental Health Act Reform

Baroness Watkins of Tavistock Excerpts

Thursday 26th January 2023 Lords Chamber

[Lord Markham (Con)]

The noble Baroness is correct; these things do need resources. We have committed to £2.3 billion of extra spending next year and an increase of 27,000 in the number of mental health nurses; I am glad to say we are well on the way, with a 7,000 increase over the last year. This all comes back to workforce planning—I am sure I will be asked that question later. And, yes, we will publish our plan soon.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister comment on why it is 50 years since we have had a revision, and say whether in fact the Government are delaying this legislation because of the resources that will be required, as has just been referred to?

[Lord Markham (Con)]

No, I hope that all noble Lords will see that there is no sense of delay on this side—and we are not waiting for the legislation to introduce a lot of these measures. It is very important, and we are ready to push on as soon as parliamentary time allows.

Osteoporosis: Early Detection

Baroness Watkins of Tavistock Excerpts

Thursday 19th January 2023 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, could the Minister comment on whether the department of health is working with the department of energy to ensure that we can afford to heat our swimming pools? Swimming is a really good exercise and reduces the risk of falls, particularly in older people.

[Lord Markham (Con)]

As previously mentioned, prevention is always better. Exercise, as I have learned from my noble friend Lord Sandhurst, is a good way of preventing osteoporosis. Where we can find cost-effective ways of getting that exercise, such as swimming pools, we should be promoting them.