Mental Health Bill [HL]

Earl Howe Excerpts

Committee stage
Monday 20th January 2025 Lords Chamber

Moved by

[Earl Howe]

23: Clause 4, page 9, leave out lines 9 to 13
Member’s explanatory statement
This probing amendment seeks to clarify the Government’s intended definition of “specified risk factors for detention” under Part 2 of the 1983 Act.

[Earl Howe (Con)]

My Lords, in moving Amendment 23 I shall speak also to the other amendments in this group, Amendments 139 and 141. These amendments, although they may not look it, are all of a piece, because they bear upon the fulcrum for any decision to detain a patient under the Mental Health Act, which is the concept of “serious harm” and what we mean by it. My noble friend Lord Kamall’s Amendment 141 offers such a definition, but we have tabled the amendment more as an Aunt Sally than anything else, because what matters is how we want the phrase to be interpreted in real-life situations by clinicians and others on the ground.

The concept of serious harm as a determining factor for detention is introduced by Clause 5. Clause 5(2)(b) replaces Section 2(2)(b) of the Act, which refers instead to detention in the interests of a person’s own health or safety, or with a view to the protection of other persons. The new wording is undoubtedly tighter than the old wording and, on that account, it is to be welcomed. However, it is not, as far as I can see, fleshed out by any definition. That could, of course, be deliberate, because, in the end, a decision to detain someone will always be a matter of clinical judgment. Such judgments, though, ought surely to rest on established understandings. Serious harm, as applied to the health or safety of the patient themselves, may be a relatively straightforward clinical judgment to make in many, if not most, circumstances. But what about serious harm as applied to the health or safety of another individual? Do we mean just physical harm or are we talking also about psychological harm? If so, of what kind and to what degree? Detaining someone on the grounds that serious psychological harm may be caused to another person raises all sorts of issues that fall outside a standard clinical judgment about the health and/or safety of a prospective in-patient.

The threshold of serious harm being caused, or at risk of being caused, is of huge significance for different types of patients. One of the really good things that this Bill seeks to do is to keep individuals with autism or a learning disability out of a mental health unit, unless they present with other behavioural symptoms that are treatable. That is because we recognise that not only is there no point in detaining such individuals when they display no treatable symptoms, it is also positively harmful to them to do so. In the same way, I think it is accepted that to detain a child or a young person forcibly in a mental health unit is a very big decision indeed, because what is meant to constitute a therapeutic environment is all too often no such thing. On the contrary, a mental health ward or even an A&E department can often seem both alien and frightening to a young patient, in a way that can exacerbate their acute disturbance of mind.

Nobody wants to see people detained forcibly in a mental health unit unless it is essential and right, but so often the choice is a binary one: to detain in hospital or not to detain in hospital. How much better it would be if, in particularly sensitive cases, there were another option, a place of safety and comfort close by in the community.

That is why I tabled Amendment 139. We know that community-based services can be a significantly positive alternative to treatment in mental health hospitals and secure units. We need to look at affordable ways of creating more, especially for those with autism and learning disabilities and for children where the alternative may indeed be forcible detention under the Mental Health Act.

The King’s Fund reported in July 2024 that

“community health services have about 200,000 patient contacts”

every day. Anxious Minds argues that community-based mental health services provide three key benefits:

“Geographical convenience of mental health facilities”,


the relative affordability of such services and, importantly, culturally sensitive approaches to care

“that appeal to diverse populations”.

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We very much appreciate the desire for accountability and scrutiny, and I want to give that assurance to Parliament as we progress these reforms. I say that as a general point, because I understand that noble Lords will have heard my responses to a number of the amendments. For those reasons, I hope that the noble Earl feels able to withdraw his amendment.

[Earl Howe (Con)]

My Lords, I thank all noble Lords who have taken part in the debate on this group of amendments. As I trust was clear from my opening speech, all three are intended as probing amendments designed to tease out some key definitions. It was actually Amendment 141, regarding the definition, that I described as an Aunt Sally.

I was particularly grateful for noble Lords’ support for Amendment 139 and for the Minister’s helpful comments. There is very little doubt that, as I think is generally accepted, community services delivered in partnership by local charities and civil society both reduce the cost to the state and carry the benefits I articulated earlier. Without implying any criticism of the NHS, those sorts of organisations will of course know their own communities better than an NHS hospital will.

I am grateful to the Minister for what she was able to say about the definition of “serious harm”. The Explanatory Notes state that a test of serious harm has been introduced

“to provide greater clarity as to the level of risk of harm that a person must present in order to be detained”.

They then state that further guidance on what constitutes serious harm will be set out in the code of practice. So far, so good, and it is welcome that that will be clarified in the code of practice, but one of the issues here is that that will come later. Serious harm is included as one of the two key tests for detention in Clause 5, so what is meant by serious harm will impact on all future decisions made within the scope of the legislation. Therefore, we need maximum clarity from the Government as we debate the Bill.

As regards the “specified risk factors”, I am again grateful to the Minister. I slightly worry that a person’s past history of admission to hospital could constitute a specific a priori risk factor for detention. There is a danger that that may turn into a directly determining factor for detention, rather than a factor to be taken into account in assessing an individual set of circumstances.

As regards drug and alcohol misuse, we need to be careful not to encourage a circumvention of the Mental Health Act, which explicitly excludes drug and alcohol addiction as grounds for detention.

I am once again grateful for the support that noble Lords were able to give to my amendments. I beg leave to withdraw Amendment 23.

Amendment 23 withdrawn.

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[Lord Kakkar (CB)]

My Lords, I support Amendment 42A in the name of the noble Baroness, Lady Browning, and I ask the Minister what justification there could be for refuting the amendment. It seems entirely appropriate, and indeed essential, that in taking such an important, far-reaching decision, one of the two registered medical practitioners who is responsible for that decision, taken at one point in the management of the natural history of disease in that individual, has the specialist skills and training to be able to make an appropriate assessment, one that will affect interventions on all future occasions for that individual.

I hope that, in addition to accepting this important principle, the noble Baroness might outline how His Majesty’s Government will go about ensuring that the development of such medical practitioners and their training is adequately resourced to ensure that, in future, as a result of the Bill being enacted, what we have seen in the past, regrettably on repeated occasions, does not remain the norm for managing patients with autism and learning disabilities.

[Earl Howe (Con)]

My Lords, I shall be very brief, because other noble Lords have already eloquently articulated the arguments that are almost self-evident about the importance of services for people with autism or a learning disability and, in particular, the importance of training all staff who may find themselves working in those fields. I agree very much with the remarks of my noble friend Lady Browning and the noble Lord, Lord Scriven, and I was particularly interested in the research mentioned by the noble Baroness, Lady Bennett of Manor Castle, which brings us into a whole new dimension, I think, in this debate.

The need to train all healthcare staff, no matter what role they perform or which part of the health service they serve in, should surely be taken as read. This should be training both in the initial identification of those with autism or a learning disability and in the skills needed to handle such individuals with the necessary sensitivity and insight. I was interested in what the noble Baroness, Lady Barker, had to say about that. The behaviour of a person who is on the autistic spectrum can be baffling to anyone who has had no experience of it, and because of that it can be open to misinterpretation. A situation of that kind carries dangers, which is why it is so necessary for healthcare staff to know how to react in a way that will make the situation better and not worse.

This is not the first time that we have debated this important topic. I believe we may be told by the Minister that mandatory training in these areas is already provided for in Section 20 of the Health and Social Care Act 2008. The provision reads:

“Regulations under this section must require service providers to ensure that each person working for the purpose of the regulated activities carried on by them receives training on learning disability and autism which is appropriate to the person’s role”.


That broad provision was inserted into the 2008 Act thanks to an amendment which your Lordships approved three years ago, during our debates on the Health and Care Act 2022.

So, a provision on training is already enshrined in law; the problem is that we have no way of knowing the extent to which it is being implemented in practice. Hence, Amendment 145 would require the Secretary of State to publish a review on mandatory training for all persons who treat patients with learning disabilities and autism under the 1983 Act and consult as necessary to determine the extent to which health service staff are actually in receipt of such training. I see this amendment as perhaps a logical partner to Amendment 152 in the name of the noble Baroness, Lady Bennett, and indeed, in his absence, to the amendment of the noble Lord, Lord Adebowale.

While the vast majority of people who provide care to people with learning disabilities and autism do so with compassion and professionalism, we have seen a number of failings in care for people with those conditions. At the same time, detention will continue to be necessary in some cases where a patient with autism or a learning disability is suffering from a separate mental health condition. In all those cases, regardless of the context in which a person presents, we need to have confidence that the people providing care have the training they need to deliver that care sensitively, and above all, capably. I would venture to say that the people who need to have most confidence in the system apart from the person receiving the care are the parents or nearest relatives of that person. Hence, I believe we need more transparency on how well the system is working than we have currently.

Incidentally, one of the things that could come out of a review of training is an opportunity to look at the current processes for whistleblowing. An important aspect of improving standards of care is to have a system of accountability that includes listening to everyone in the sector, from the most senior staff to the most junior. No one should be afraid to speak up when they see something going on that does not look right, and I should be very grateful to hear what the Minister has to say on this whole theme and on the other important issues that noble Lords have raised.

[Baroness Merron (Lab)]

My Lords, I express my gratitude to noble Lords, not just for their amendments but for the way in which this debate has been conducted. I appreciate much of what lies behind the contributions and amendments today.

I first turn to Amendment 33, tabled by the noble Lord, Lord Scriven, and supported by the noble Baroness, Lady Hollins, and also Amendment 150 in the name of the noble Lord, Lord Adebowale. All of these were spoken to throughout this group, including by the noble Baronesses, Lady Tyler and Lady Murphy. I noticed that Amendment 150 was particularly referred to by the noble Lord, Lord Patel, and the noble Earl, Lord Howe.

On the matter of data collection, I absolutely share my noble friend Lord Beamish’s view on its importance, the need for the visibility of data and the need to find out what is behind detention. However, I can give the reassurance that the data and statistics that were referred to are being collected and published. They will continue to be monitored and published monthly in the assuring transformation statistics for learning disability and autistic people, and I hope that will be helpful to my noble friend.

The amendments I am referring to, which the noble Lord, Lord Scriven, introduced, require the Secretary of State to publish plans within a specified timeframe, outlining the Government’s plan to allocate sufficient resources for the commissioning of services for the detention and treatment of autistic people and people with a learning disability, as well as costed plans which show how integrated care boards and local authorities will ensure provision of adequate community services for these groups.

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[Lord Meston (CB)]

My Lords, I hesitate to interrupt, but I want to make much the same point that the noble Baroness has made based on my experience of a trip to A&E last year. I mentioned it anecdotally at Second Reading. There was a very disturbed person in A&E when I was having to wait there for some three hours. The hospital staff were struggling to contain the person in one room, as he kept leaving. He was not violent, but he was obviously distracting the hospital staff and worrying the other people present, who included children. As soon as anybody asked the staff what they were going to do, they said that they had to wait for the police. I have no doubt that the whole episode that I witnessed was prolonged by the need to wait for the police. Clearly, if this amendment or something like it is approved, it will widen the range of those who could be called upon to deal with such a crisis.

[Earl Howe (Con)]

My Lords, there is little for me to do following the persuasive speech of my noble friend Lady May, other than to say how much I support her in putting forward her amendments. I hope that the Minister will approach the proposals my noble friend has made in a receptive and constructive way.

I was struck by the case put forward by my noble friend Lady Buscombe about how technology could assist in the handling of mental health incidents. I hope equally that the Minister will wish to follow up on my noble friend’s suggestions.

The question of whether police officers, and only police officers, should exercise the powers under the Act to remove a person suffering from a mental health crisis to a place of safety is one that, as my noble friend Lady May said, has been simmering in the Home Office and the Department of Health and Social Care for a decade or more. Extending those powers to suitably trained healthcare professionals would be a change that I suggest goes with the grain of this Bill as regards the emphasis that it places on looking after mental health patients in the best possible way. That is not a criticism of the police in any sense. The police do a magnificent job in tackling anything that they are called upon to do, but, as we have heard, the police themselves say that the vast majority of instances in which they are called upon to deal with a mental health incident do not require a policing response.

The issue of risk is important to consider. Statistically, as my noble friend said, most mental health incidents present no risk whatever to the police attending. Admittedly, it is not always possible to tell in advance how risky a particular encounter is likely to be, but I agree with my noble friend that, provided that a paramedic is suitably trained and equipped, they will have the necessary skill set to deal with any risk to their own safety, bearing in mind that if a police presence turns out to be necessary, they can always call for one.

I very much hope that, between now and Report, the Minister will agree to meet my noble friend, if that is what she wishes, to map out a way forward that will lead to a broadening of the Sections 135 and 136 powers.

[Baroness Merron (Lab)]

My Lords, this has been an interesting debate, with much agreement across the Committee. I noted the support from both the other Front Benches, from the noble Earl, Lord Howe, and the noble Baroness, Lady Tyler, for much of what has been said.

Let me first discuss Amendments 37B, 38C, 42C, 42F and 128B in the name of the noble Baroness, Lady May, along with Amendment 158 in the name of my noble friend Lord Davies of Brixton. I am most grateful to the noble Baroness and my noble friend for bringing this issue before the Committee today. Amendments 37B, 38C, 42C and 42F would add a new category of authorised persons and would provide that police constables and such authorised persons may detain a person under Sections 2, 3 and 5 of the Act.

I share the recognition from the noble Baroness, Lady Barker, of the noble Baroness, Lady May, who I commend for her work to pave the way and dramatically reduce the use of police cells as a place of safety for those who are experiencing a mental health crisis. I listened carefully to the noble Baroness’s words of advice to all government Ministers; all I can say is that I cannot think how much better we could be advised than by a former Home Secretary and Prime Minister.

I thank the noble Baroness, Lady Watkins, for what I might call her notes of caution in respect of extending provisions, and the noble Lord, Lord Meston, for sharing his first-hand experience to add to the debate today.

We understand the broad intention of these amendments and of Amendment 128B, also in the noble Baroness’s name, to reduce police involvement in mental health cases for all the reasons that were said, including the extra distress that an officer may—inadvertently, of course—bring to a very delicate crisis situation.

The noble Baroness, Lady May, asked how the Bill will ensure that pressure is not placed unduly on police resource. I understand that that is very much a driving consideration, so let me say a few things on that matter. We recognise the pressure on the police, who are responding to a very large volume of mental health-related incidents, although—this is not to dismiss the point—detentions under Section 136 have decreased this year by 10%, and we are removing police cells as a place of safety to reduce some of this burden. We recognise, in particular, that police time in health settings should be reduced. I give an assurance that we have committed to look at this issue and to update the code of practice to clarify the handover process between police and health, including in A&E, which the noble Baroness, Lady Tyler, spoke about. We recognise the confusion around the application of the legal framework that can tie up police time when it would be lawful for them to leave a patient with health staff.

Mental Health Bill [HL]

Earl Howe Excerpts

2nd reading
Monday 25th November 2024 Lords Chamber

[Earl Howe (Con)]

My Lords, I begin by extending my gratitude to the noble Baroness, Lady Merron, for introducing the Bill into your Lordships’ House and for her very clear exposition of its contents. It is a Bill that we on these Benches warmly welcome. That welcome should not come as a surprise because, as the noble Baroness said, the Bill before us is the successor to a draft Bill prepared by the previous Government, a draft that owed its origin to my noble friend Lady May, on whose watch a review of the 1983 Act was initiated some seven years ago during her time as Prime Minister. Much of what we see laid out here is the product of diligent work carried out by Professor Sir Simon Wessely and his review committee, as well as the Joint Committee of both Houses, so ably chaired by my noble friend Lady Buscombe.

The passage of the Bill presents us with a golden opportunity to address both the current state of mental health provision and the law that governs it. The last major update of the Act took place in 2007 under the previous Labour Government. That may not sound like a long time ago but, as we shall no doubt hear from others, experience gained in the intervening years has taught us that a further update is indeed warranted if we are to ensure that the Act remains relevant and appropriate, and that its powers are proportionate.

Wherever the state uses its powers to deprive an individual of their liberty, the necessary safeguards must be in place so that those powers are used sparingly, proportionately and with the highest regard for human dignity and autonomy. That is why the Bill is so important. Since the last set of changes to mental health legislation in 2007, the number of people being detained under the Mental Health Act has grown exponentially. In fact, since 1983, the numbers have nearly doubled to a total of over 52,000 new recorded detentions between 2023 and 2024.

Within that total, we have also seen a stark disparity in the classifications of those being detained. Black people are 3.5 times more likely to face detention under the Act. Shockingly, to my mind, there are currently over 2,000 people with autism and learning disabilities detained in mental health hospitals across the country. I was equally shocked by the realisation that people with autism can be detained even if they do not have a mental health condition, leading to disproportionate, burdensome and wholly inappropriate treatment.

These issues occupied centre stage in the Wessely review, which proposed the formal recognition of four key principles that should from now on govern both theory and practice in this area of the law. The principles are: choice and autonomy; least restriction on liberty; therapeutic benefit; and the person as an individual. The previous Government fully accepted these four principles and—giving life, as it were, to those principles—the draft Bill set out to make a number of important changes. It strengthened the rights of patients with a learning disability, it gave patients greater autonomy in choosing how they wish to be treated, it introduced duties on commissioners to better understand and support people with a learning disability or autism, who may be at risk of crisis, and it sought to update community treatment orders, which are one of the key drivers of racial disparities in the numbers of people subject to restrictions under the Act.

It is therefore very pleasing indeed to see this Government’s firm commitment to enacting exactly these reforms, and I, for one, hope that as the Bill proceeds, we can come together as a House to implement and, where necessary, improve this hugely beneficial set of changes.

With consensus as the thread that, happily, we expect to run through our consideration of the Bill, there are nevertheless certain themes within it that are likely to require our particular attention. The first of these is community treatment orders. CTOs were first introduced in the Mental Health Act 2007. The Joint Committee on the earlier draft Bill was very clear that CTOs had been widely overused and that they are one of the leading causes of the racial disparities that I referred to a minute ago. The Bill before us makes a number of changes to the criteria governing the use of CTOs, all of them designed to support two of the key principles in the Bill: those of least restriction and therapeutic benefit.

As far as they go, these changes are desirable. However, the Bill stops short of including the full suite of recommendations made by the Wessely review. The Centre for Mental Health has raised this as a key concern. It points out that there is still no persuasive evidence of the benefits of CTOs. Against that background, it argues that a number of checks and balances are needed on the use of CTOs in future, over and above those already in the Bill. In particular, it notes that the committee recommended a full statutory review of the use of CTOs to report within a fixed timeline, which, on the face of it, is the least that we should be doing. I think we will want to debate in Committee why the Government have not felt it appropriate to go as far as the Joint Committee and the independent review recommended in this area.

The next important theme is children and young people. According to NHS data—and this was highlighted by the noble Lord, Lord Darzi, in his recent review—932 children in mental health units were subject to restrictive interventions in 2023-24. In total, more than 84,000 restrictive interventions were carried out on these children, which is a 51% increase from the year before. This is the highest number of restrictive interventions recorded since figures were made available in 2019, and that is despite the number of children in mental health units appearing to decrease.

We have a duty to use the Bill as an opportunity to identify ways of reducing such restrictive interventions and using them more humanely and more proportionately. Two years ago, the Government launched the Oliver McGowan training for NHS staff to help them better deal with young patients with autism. Noble Lords may remember that this was in response to a truly harrowing and appalling set of occurrences that ended with the death of a young man. It is fair to say that the case shook the health service to its core. I believe we have in the Bill the opportunity to take forward those lessons so as to protect children who may be at risk from unwarranted detentions.

The independent review and the Joint Committee had much to say about how treatment of children under the Mental Health Act could be improved. Unfortunately, by no means all those recommendations have found their way into the Bill. One such omission relates to the inappropriate placement of under-18s into adult wards or facilities that can sometimes be miles away from their home. The Joint Committee found that in each of the years 2016-17, 2017-18 and 2018-19, over 1,000 children were placed out of area, and that in 2020, 21% of children and young people were placed as in-patients more than 50 miles from their home.

It is perfectly obvious that being taken to an unfamiliar environment in a place far away from friends and family is almost guaranteed to exacerbate the issues young people face when experiencing a mental health crisis. On top of this, data from the Care Quality Commission showed that in 2021, 249 children and young people admitted for mental health treatments were housed on adult wards for more than 48 hours, some for a good deal longer than that. These are uncomfortable figures; I hope noble Lords on all sides of the House will want to ensure that, through this Bill, we take all possible steps to bear down on the scale of these problems and strengthen the protections afforded to children and young people.

One of the core themes that has remained prominent throughout the process that has led to this Bill is that of choice: giving patients as great a degree of autonomy as possible in how they are treated and maximising their ability to determine what happens to them if they are detained. In that regard, I think the Bill succeeds on many counts, but one measure recommended by the Joint Committee was that there should be a statutory right to an advance care document for every patient who has been or may be detained under the Mental Health Act. The Bill, as it stands, does not follow up on this recommendation. Instead, it places a duty on NHS England and integrated care boards to make information regarding such documents available to patients. I do not doubt that this is a beneficial reform, but we should debate whether it goes quite as far as it usefully might. Guaranteeing patients and service users the chance to state and record their preferences for care and treatment plays directly into the key principles of choice, autonomy and treating every person as a rounded individual—so what are the barriers to doing that?

There are a whole host of detailed issues which we will need to cover in Committee. The final, major area I want to touch on is that of the role played by the police. Inevitably, circumstances arise in which the police are required to become involved with people who may be a risk to themselves or to others. There is a strong feeling that encounters with the police are far too common for people with mental health conditions. As the independent review and the National Police Chiefs’ Council have pointed out, the presence of the police in situations where a mental health issue poses a risk of serious injury or death can be counterproductive. In its written submission to the Joint Committee, the Metropolitan Police stated that:

“Our officers simply cannot provide the specialist care needed, exposing both patients and officers to extreme risks”.


The NPCC has also expressed its concern that the role of the police in mental health pathways must be reduced.

It is welcome that the Bill goes some way to addressing this. Clause 46 removes police stations and prisons as places of safety, thereby preventing patients experiencing mental health crises from being locked up inappropriately. However, there is a potential knock-on effect that we should talk about in Committee. Well-intentioned as the provision is, it could well lead to a rise in people being admitted to accident and emergency departments, escorted by the police, and having to wait in crowded spaces with the lack of the necessary, specialised facilities until they can be assessed by clinicians. In this environment, the risk of harm could well be multiplied. We need to ask how this risk can best be mitigated. I fear that any realistic answer will need to involve resources, by which I mean taking steps to ensure that the requisite arrangements are made for NHS trusts to deal with an increase in the number of mental health patients being admitted to hospitals as places of safety. This is not an easy set of issues, but it is a subject that we cannot duck.

Parliament must see to it that wrongful, inappropriate and untherapeutic detentions of those undergoing a mental health crisis are brought to an end. The Bill provides us with a necessary and welcome opportunity to transform the treatment of those with mental health conditions and to bring both doctrine and practice well and truly into the 21st century. Along with my noble friend Lord Kamall, I look forward to working with the Minister and with noble Lords on all sides of the House to scrutinise and—where we can—improve the Bill’s provisions. Many thousands of the most vulnerable members of our society are depending on us to do so.

NHS: Independent Investigation

Earl Howe Excerpts

Tuesday 8th October 2024 Lords Chamber

[Earl Howe (Con)]

My Lords, I am glad we are having this debate on the report by the noble Lord, Lord Darzi, even if the tone set by the Statement—which I am sure noble Lords have read—is, as far as I am concerned, rather regrettable. It is regrettable because the noble Lord, as one would expect of that most distinguished man, has produced a thoughtful and carefully argued diagnosis and set of prescriptions for the NHS. It would have been better to treat those findings on their own terms rather than as an excuse for a highly charged political rant. Having said that, I hope that, in this House at least, we can maintain debate on a rational and civilised level.

There are indeed problems in the health service that are there for all to see and others that are less immediately visible. These problems are real and indeed require sustained remedial effort. The noble Lord, Lord Darzi, attributes them to a mixture of causes, one being inadequate central government funding. I do not expect the noble Lord to be an apologist for the previous Government, but it would have been nice if he had acknowledged more fully that, despite so-called austerity, health service funding rose in real terms in every year since 2010 and in the last five years by nearly 3% in real terms per annum. The problem, as Sir John Bell has pointed out, is not a lack of money: it is that too much of the money has been sucked, suboptimally, into acute care settings and not enough into the community. The noble Lord goes on to say that very thing. But let no one conclude from that that community funding has been neglected. The last Government oversaw the opening of 160 community diagnostic centres. As my right honourable friend said in the other place, this is the largest central cash investment in MRI and CT scanning capacity in the history of the NHS.

Is there more to be done? Yes—but the results are there and proving their worth. The NHS is currently treating 25% more people than it did in 2010. It is delivering tens of millions more out-patient appointments, diagnostic tests and procedures than it did when the coalition Government came into office. Some of the community services are being delivered by staff employed by acute trusts—the statistics tend to hide those numbers. Yes, we can talk about the need for greater productivity, but this progress—it is indeed progress—is all down to the efforts of the dedicated clinical staff across the health service on whom we all rely, and who are more in number than at any time in the service’s history.

Please do not criticise the last Government for focusing on the numbers. The imperative of planning ahead to train the right number of staff for the right care settings was amply fulfilled in the last Government’s workforce plan—a publication heralded by the NHS chief executive as

“one of the most seminal moments”

in the NHS’s history.

Can the Minister nevertheless say, despite the fact that the report is not mentioned by the noble Lord, Lord Darzi, whether the Government will embrace the workforce plan and take it forward as the NHS clearly wants and needs? Can she also say whether the Government will adopt the productivity plan announced in the last Government’s Spring Budget? That plan—again, unaccountably not mentioned in the report—would deliver the “tilt towards technology” that the noble Lord rightly advocates, with a big productivity gain to boot.

I said that the noble Lord, Lord Darzi’s report was carefully argued, but not all of it is well argued. I cannot allow his colourful statements about the 2012 Health and Social Care Act to go unchallenged. To attribute the NHS’s current difficulties and challenges in large part to that Act is, frankly, ridiculous. What that Act did was to complete the process that the noble Lord himself started, which was to ingrain quality into the commissioning and delivery of healthcare based on clearly defined standards and outcomes, meaning that providers would be competing with each other based on the quality of care and treatment that they delivered to patients.

The noble Lord, Lord Darzi, now says that we need to move away from the whole idea of competition, but I suspect he has misled himself, because he goes on to say:

“The framework of national standards … incentives and earned autonomy … needs to be reinvigorated”,


along with patient choice. What is that framework if it is not a framework of healthy competition between providers based on quality? Therefore, what role does the Minister see for competition alongside collaboration —I do not think the two are mutually exclusive—in driving up the quality of NHS care?

I have a few final questions. We are told that a 10-year plan will be produced based on the findings of the noble Lord, Lord Darzi. Whose plan will that be? Will it be the Government’s plan, and if so, how will the Government avoid what might look like a prescriptive top-down set of instructions to the health service? Does the Minister think it important that the NHS takes ownership of the plan and, if so, how will that be achieved?

In essence, the noble Lord, Lord Darzi, believes that we need to get from point A to point B—in other words, from acute settings to community settings; from tired old premises to brand new ones; et cetera. Does the Minister agree that we cannot transition from point A without first finding the money to create a functioning point B? In other words, will she and her fellow Ministers urge the Chancellor to commit to the capital expenditure necessary to achieve that?

Lastly, I quote the noble Lord, Lord Darzi:

“The vast array of good practice that already exists in the health service should be the starting point for the plan to reform it”.


Does the Minister agree with that and, if so, how does she reconcile those sentiments with the Government’s mantra—which is so discouraging to the men and women of the health service—that the NHS is “broken”?

[Lord Scriven (LD)]

My Lords, I thank the Minister for bringing the Statement to the House. You do not have to be a mastermind to realise that the NHS is straining at its seams. It is only down to the great work of the many thousands of people who work in the NHS that millions of people get great care, even though some fall between the cracks.

The Darzi report is a very good medical history and it gives a diagnosis, but we all know that the treatment plan is going to be the important point if we are to deal with a reformed, new and productive NHS. There are some welcome themes in the report that are not new. Those who know the previous Darzi report will see have seen some of them before: prevention; moving resources from hospital care to primary and community care; dealing with the wider determinants of health; improvements in and parity for mental health; and a bigger role for public health.

I understand that the Minister will answer many questions by saying that we need to wait for the 10-year treatment plan, and probably the Budget, before such specific questions can be answered, but I have a few general questions for the Minister, to get at least a sense of the direction that the Government wish to take.

Is it the Government’s intention to restore the public health grant back its 2014 levels? Are there any general views about looking at changing the structure of public health, nationally or locally? On capital, what is the Government’s thinking about the general theme of allocation to hospital and non-hospital services, and how will this be managed and monitored? On data, what is the Government’s thinking on the workforce plan, particularly when there is a huge imbalance when it comes to digital and data between the private sector and skills within the NHS? That is not to say that there are not some good skills within the NHS, but there is clearly an imbalance.

Welcome as it is that the report talks about moving resources from hospital to non-hospital settings, I was a manager in the health service in the early 1990s and I know that this has been said since at least the 1970s. What are the Government going to do to be able to move resources from sunk costs in the acute sector into other sectors? What mechanisms will be put in place? How will this be monitored? More importantly, who will be held accountable for making sure that it actually happens? How will the new neighbourhood approach affect the existing workforce plan? If a new health service is anticipated, what will the effect be on the workforce plan and the implications for capital allocation?

We all want to see a productive and effective healthcare system that improves peoples’ health and independence, but that cannot be brought about if we do not have a strong, effective, well-funded social care system. I do not understand why social care has been kicked down to the next Parliament, or how we are going to solve the health and well-being of the population without that being done. If the major reforms of social care are in the next Parliament, what steps are the Government going to take in this Parliament to deal with the social care crisis?

I look forward to the Minister’s answers, but, more importantly, to the 10-year treatment plan’s arrival in the next few months.