Mental Health Bill [HL]

Committee (2nd Day)

16:10:00

Clause 4: People with autism or learning disability

Amendment 23

Moved by

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.

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”.

16:15:00

It is good news that the Government have already signalled their intent to support greater access to community-based services. The 2024 Labour Party manifesto was explicit in that regard, as was the noble Lord, Lord Darzi, in his review of the NHS, which called for a shift in focal points for care. So I hope that the Minister will be supportive of Amendment 139, at least in principle. I will be glad to hear her comments on widening access to community mental health services and how the Government propose to ensure that the necessary numbers of trained staff are available to deliver those services.

I described the concept of serious harm as the “fulcrum” for decisions to detain a person under the Act. However, it is of course only a part of that fulcrum because, as we will see from the amendments tabled by the noble Baroness, Lady Murphy, in the third group we will be debating today, the other element integral to such decisions is a judgment around risk. I will not pre-empt the debate we will have when we get to the third group, but I will make a couple of points about my Amendment 23, which addresses a slightly different aspect of the risk issue.

In Clause 4, new Section 125D would mandate each integrated care board to maintain a register designed to record details of individuals with autism or a learning disability, and regulations will be laid about the information that the register must contain. There is a two-pronged criterion for someone’s inclusion in the register. The first is that they must be someone whom the ICB considers to have autism or a learning disability, and the second is that the person has

“specified risk factors for detention under Part 2 of this Act”.

Those specified risk factors will be set out in regulations. It would be very helpful to hear from the Minister what the nature of those specified risk factors will be. I say that not just to hark back to the point I made earlier about the acute sensitivity of any decision to detain someone in a secure facility when they have autism or a learning disability; there is a broader concern that I think is material. We are talking here not about a clinical judgment made on the ground by a clinician that someone may pose a risk of serious harm, but rather about an a priori categorisation by the ICB of specific named individuals in accordance with regulations made by the Secretary of State.

The Explanatory Notes for the Bill state that the specified risk factors are

“factors which the Secretary of State considers increase the probability of a person being detained under the Part 2 of the Act”.

What might those factors be? What are the things that the Secretary of State can take it upon themselves to determine as regards the risk that X or Y might pose without pre-empting the judgment of a clinician or a police officer in a particular set of circumstances?

In asking the Minister that broad question, I want to home in on a narrower one. The Care Quality Commission has argued that there have been changes to the risk factors for detention under the Mental Health Act, and that these are among the reasons for the rising rate of detentions. In its 2018 report, Mental Health Act: The Rise in the Use of the MHA to Detain People in England, it notes that among these factors are the rising rates of the number of people admitted to hospital with mental health problems due to drug and alcohol misuse. It says:

“The number of hospital admissions with a primary or secondary diagnosis of drug-related mental health and behavioural disorders doubled between 2004/5 and 2014/15”.

Clinicians interviewed for the report stated that not only were the numbers increasing but that drug use, specifically of synthetic cannabinoids such as Spice, has increased the severity of mental health conditions.

The CQC links that to rising detentions under the Act, because they can lead to a “greater likelihood” of people displaying behaviours that meet the threshold for detention under the Act. That is despite the fact that they may not have any form of mental disorder. Can the Minister say whether mental illness arising from drug misuse is likely to play any part in the decisions that the Secretary of State will make around what might constitute a specified risk factor that increases the risk of detention under Part II? I beg to move.

My Lords, as the noble Earl, Lord Howe, has mentioned, we will be talking about risk factors in the next group but one, and I will not go into the statistics and predictions at this point. As has been pointed out, Clause 4 implies that specific risk factors for detention under Part II are readily identifiable and assessed, but as we will see, predicting episodes of violent behaviour or self-harm is peculiarly difficult to do. The clause suggests that it is not clinicians who will be doing these risk assessments but that the Secretary of State will somehow have some expertise from ICBs in how to do this. Apart from the rather obvious wisdom that the best predictor of future behaviour is past behaviour, I am not sure how these regulations can be drawn up. I am anxious about the common prejudices around, for example, black patients of African Caribbean descent living in London, who have a higher risk of being detained under Part II than white patients, or Asians of an Indian subcontinent background. Who will draw up this list to say which of these items is going to lead to the risk of detention under Part II? There have always been opportunities for the Secretary of State to intervene in the detention of patients under Part III of the Act, and some Secretaries of State have been more risk averse than others. I suspect that under this clause we will find some Secretaries of State taking a more hard-line view about who should and should not be detained. That gives cause for enormous anxiety, so I would like to know how the Government intend to devise these regulations to document specific risk factors.

My Lords, this is an important set of amendments, and, as the noble Earl, Lord Howe, said, they are central to decisions about whether to detain people under the Act. I agree that the definition of “serious harm” is important, and it would be helpful to hear from the Minister what the Government are thinking there, how it will be applied, and how any thresholds will be established. I endorse what the noble Earl had to say about children and young people, what a huge decision it is to detain someone under 18 in hospital against their will, and how hard we need to work to avoid that, whenever that is safe for themselves and other people. Finally, and very much linked to that, I strongly support Amendment 139 on the availability of community-based services, which we have already talked about and which we will turn to in subsequent groupings. It is a very good amendment, particularly the provision which states: “The Secretary of State must publish a report to assess whether there should be more community-based services for community patients in order to prevent”— I see this as a key preventive measure— “detention under the Mental Health Act 1983”. My one point is that the amendment talks about publishing that within two years of the day on which this Act is passed. I personally think that in an ideal world we might see a report a bit earlier than that. However, as I say, Amendment 139 certainly has my full support.

I am sorry that I did not jump up in time before my Front Bench spoke. I just wanted to add my voice to support Amendment 139 in the name of the noble Earl, Lord Howe, and the report on community-based services. It is really timely and we need it. The case was made very carefully and well by others, so I will not expand much other than to say that an extensive report was done in November by the leading charity, Beat, which looked at the case for more intensive community care and daycare for people with eating disorders in order to avoid—the very point that the noble Earl, Lord Howe, made—ending up getting to such a point of severity that they need to go into mental health facilities and be detained, which indeed happened to my daughter, as I made clear at Second Reading. The case has been well made that a report should be made. I agree with my noble friend Lady Tyler that two years seems quite a long time off, particularly as recent work has been done, particularly in the field of eating disorders, to show that you can both reduce the number of patients and reduce the cost if you make the investment up front in community services.

My Lords, as an ex-community mental health nurse, I wish in particular to support Amendment 139. I am convinced that we need appropriate ratios of such staff to deliver preventive services in the community as well as ongoing support. We need to remember that the NHS rests in the future on preventing rather than treating, and this is an important amendment that acknowledges that.

My Lords, I want to add to what the noble Baroness just said. Amendment 139 goes to the heart of the Bill in terms of changing the culture and the way that we treat people. The Bill will become a piece of law that is practical only if we can honestly put hand on heart and say that we will substantially increase community-based services. Without that, it will not deliver that which we all believe will be the minimum to improve people’s lives.

My Lords, on the amendment outlining the definition of “serious harm”, two situations were raised with us on the Joint Committee. One was that the change in the criteria is the main tool that will help with racial inequalities; I would be grateful if the Minister could outline how she envisages that will work in practice. The second point was about the period during which such serious harm has to be exhibited. We heard numerous times about people with psychosis, many of whom—I think it was over 70%—do not realise that they are getting ill when they are presenting. How poorly do they have to get? Sometimes the intervention might need to be sooner than in the definition we understood of “serious harm”, which was slightly different from that which the independent review had, which I think was of “significant harm”. If the Minister could address those two points, that would be very helpful.

My Lords, I thank noble Lords for their contributions to this important debate in which a number of key issues have been raised. Amendment 23, tabled by the noble Earl, Lord Howe, and supported by the noble Lord, Lord Kamall, relates to new Section 125D, regarding registers of people with a learning disability and autistic people who are at risk of detention. The amendment would remove new Section 125D(5), which defines “specified risk factors for detention”. I heard the noble Earl, Lord Howe, refer to this as an Aunt Sally amendment—I politely have “a probing amendment” here but I hope that we are in the same area—that is intended to clarify the definition of “specified risk factors for detention under Part 2 of this Act”.

16:30:00

To address one of the noble Earl’s points, it is important that the Bill makes provision for the risk factors to be specified, as the purpose of this clause is to identify and collate information about people who have such risk factors due to their potential need for additional support to prevent a future detention under the Act. As an illustration of the type of information that is envisioned, current NHS England guidance on dynamic support registers describes risk factors such as a previous mental health hospital admission or the person presenting in crisis at an A&E department. However, work to establish and agree a comprehensive list of the risk factors for inclusion will be commenced in due course. I make this point also to the noble Baroness, Lady Murphy, and other noble Lords who raised what the risk factors may be.

The noble Earl also questioned whether alcohol and drug addictions would play a role in specified risk factors for detention under Part II. Guidance has been published by NHS England. It includes a list of some known risk factors. Drug and alcohol addiction are currently listed in that guidance. We will be considering that very seriously as we develop the regulations. I hope that my comments about the kind of guidance in dynamic support registers will also be helpful. Going back to that point about NHS England guidance on dynamic support registers, I hope it is helpful to point out that there is a fuller list in the appendix of that document, which the noble Earl might find helpful. It includes drug and alcohol addiction.

Regarding the risk factors for detention under Part II, these will be updated regularly in line with evolving clinical practice and policy. Setting this out in regulations will allow sufficient flexibility for risk factors to be updated and to ensure that the law can be kept up to date.

Amendment 139, tabled by the noble Lord, Lord Kamall, and supported by the noble Earl, Lord Howe, places a duty on the Secretary of State to publish a report within two years of Royal Assent to assess whether there are sufficient community-based services. I heard the comments from other noble Lords, including the noble Baronesses, Lady Parminter, Lady Tyler and Lady Buscombe, particularly the reference by the noble Baroness, Lady Parminter, to the important matter of eating disorders. As with community support for people with a learning disability, and autistic people, which we are also discussing today, we are committed, as noble Lords have heard me say, to working with stakeholders to develop implementation plans. I understand the sentiment, but we are reluctant to commit to a single report at a specified time. I hope noble Lords understand that the implementation plans need to fit in with other developments, including spending reviews and the 10-year health plan.

Clearly, reducing detentions depends on services in the community. I certainly can share the noble Earl’s positive reflections on the value of good-quality and appropriate community services, and I am glad that he welcomes this Government’s shift towards community-based provision—that is something which I hope we can all continue to work on together.

Clearly, an assessment of detention considers a number of factors—I believe this is something the noble Baroness, Lady Buscombe, also raised. These factors are personal attributes, knowledge of the individual, what potential risks may occur—that is something I will turn to shortly—and whether a suitable alternative to detention is available; for example, through community provision which can safely, I emphasise safely, support the patient.

Expansion and transformation of NHS mental health services is very necessary. In your Lordships’ House we know the reality is that much more must be done, as many people are not getting the care that they need. The NHS is piloting 24/7 mental health centres in six areas, and that is based on international evidence about how care can shift from hospitals to the community, with easier access to help for people who need it. I am sure I am not alone in being extremely interested to see how these pilots work; it is exactly the kind of thing that noble Lords have rightly called for.

Amendment 141, tabled by the noble Earl, Lord Howe, and supported by the noble Lord, Lord Kamall, seeks to define what is meant by references to “serious harm” in the detention criteria, which the noble Baroness, Lady Tyler, also referred to. Perhaps I could say, more generally, before I come to that third amendment in the group, that a number of important contributions have been made today, and certainly we will return to them in later days in Committee, which I think will be helpful.

The noble Baroness, Lady Berridge, asked why the word was “serious” rather than “significant”. The reason is that “serious” has an established legal basis and interpretation. I assure the noble Baroness that we explored this area from the review and looked at the proposals to explore where we should go, but that is the reason that we came to that place.

We agree, in respect of the amendment specifically, that the circumstances set out may amount to “serious harm”. However, we do not want to be too prescriptive in primary legislation, and I know that noble Lords will have heard this on other occasions. The reason is, as noble Lords will understand, that clinicians must be able to use their clinical judgment. The code of practice clarifies examples of harms, including psychological and physical harm, which the noble Earl, Lord Howe, spoke about. We will consult stakeholders to update the code of practice with further guidance on what constitutes “serious harm”, including case studies and illustrative examples.

The noble Baroness, Lady Berridge, asked whether the change of criteria will be the main tool to reduce inequalities, and how that will work in practice. We will be working very carefully with the wider mental health system to support the effective implementation of the provisions of the Bill in order to reduce racial disparities in decision-making, because, after all, that is one of the key reasons for bringing forward the Bill. Certainly, updating the code of practice will help and will make a major contribution towards that. We want to make sure the code is absolutely clear on the actions that can be taken to avoid and address racial disparities in the application of what we hope will become the Act.

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.

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.

Amendments 24 to 32 not moved.

Amendment 33

Moved by

33: Clause 4, page 9, line 40, at end insert— “125FA Report: sufficient commissioning services for people with autism or learning disabilities(1) Within four months of the day on which the Mental Health Act 2025 is passed, the Secretary of State must lay before Parliament a plan to allocate sufficient resources for commissioning services regarding the treatment and detention of autistic people and people with learning disabilities to ensure operability of provisions in this Act.(2) The plan must include—(a) revised assumptions of the number of autistic people and people with learning disabilities who may require detention under this Act;(b) the actions that the Secretary of State will take to ensure community services are available to meet demand after the 28-day detention period;(c) plans for data collection to support commissioning sufficient services;(d) plans to allocate appropriate resource to ensure operability of services, including, but not limited to, financial resource;(e) plans to ensure that responsible bodies and individuals receive the necessary training to carry out support, diagnostic, and treatment plans.”Member's explanatory statement This amendment requires the Secretary of State to present a plan within four months to ensure sufficient services, resources, data, and training are in place to support autistic people and those with learning disabilities under the Act.

16:45:00

This group of amendments has to do with learning disabilities and autism, and the implementation of the Government’s recommendations, particularly on the change in detention criteria. My Amendment 33 is probing; I shall come to its details shortly. The Committee needs to look into this subject, because many times before in government policy we have seen a good aim and good intentions of moving care into the community, but all too often the facilities have not been there, and people have ended up in crisis. I tabled Amendment 33 to probe the Government’s staged approach to ensure that community facilities are in place before the change in detention happens, and to understand their timing. On page 72 of the impact assessment, the suggestion is that the change will not happen until the community facilities are in place. That is good, but that could be five, 10 or 15 years away, so the Committee needs to understand the Government’s approach to timing. Amendment 34, tabled by my noble friend Lady Barker, and the amendment tabled by the noble Earl, Lord Howe, cover mandatory training for medical staff and others associated with looking after people with learning disabilities and autism, to detect the signs, so that people are not missed and put into detention. My Amendment 33 would create an obligation for the Government to lay a costed plan for sufficient services before Parliament within four months of the passage of the Bill. The four-month period is important, because we really need to understand the Government’s intentions on timing. The change in detention criteria for autistic people and people with learning disabilities is a vital change in the Bill, to ensure that people are not inappropriately detained but are supported in the community instead. As I have said, success depends on there being sufficient services in each area across the country to meet the needs of autistic people and people with learning disabilities. Based on the impact assessment, we know that the Government do not plan to enact those, so it is important that when the Minister replies, she lets the Committee know exactly what the timing is and what the Government’s assumed plans are. In the equality impact assessment, there are dates for both funding and implementation, which seem to be at the same time. As a former NHS manager, I can say that people cannot start a service involving such a change and receive the funding in the same year. There has to be upfront funding to enable people to plan the services over time. Otherwise, the services are not there, and staff run round trying to get services when people are in distress. It is important to understand that. Additionally, as the NHS long-term plan target to reduce the number of detentions of autistic people and people with learning disabilities has been missed, there are no active targets to get people out of hospitals. My amendment tries to put in targets to hold the Government and the services to account on ensuring that people are not inappropriately detained. It is important to have a comprehensive action plan, which is what my amendment seeks to do, and to find out exactly how the Government intend to build and fund those community services moving forward. Additionally, this must include new targets to reduce the number of detentions of autistic people and people with learning disabilities. The timelines for building this support will also be crucial if the Government are to meet the expected 2026-27 commencement date for the new detention criteria for autistic people and people with learning disabilities. I hope that the Minister will fully brief the Committee so we can make an informed decision about not just the thinking of the Government but the detailed implementation around community services with the change of criteria. I look forward to hearing noble Lords speak to their amendments on the provision of training and the appropriateness of medical practitioners’ expert knowledge of learning disabilities and autism. I beg to move.

My Lords, I shall speak to my Amendment 34. As I do so, I extend my condolences to the noble Baroness, Lady Hollins. We miss her very much today. She was extremely helpful to me only a few days ago when we were discussing the subject of this amendment, so I hope I do her a lot of justice with this. We have heard time and time again that people with learning disabilities and autism find themselves on the wrong end of diagnoses made by practitioners with the best of intent, quite often when people are at points of severe distress, that are inappropriate because the people making them have not perhaps had the degree of experience and knowledge of working with people with learning disabilities and autism as they would otherwise have done. We started to discuss last week that, while there are mental disorders for which detention in the sorts of facilities that we fund in acute hospitals in the NHS is right and appropriate, there are also some people for whom detention in those circumstances is absolutely not; it is an aggravating factor. Therefore, in my amendment I am seeking to address that issue: not just the competence of the people making decisions about detention and treatment but also the confidence with which they, as professionals, can approach the jobs that they are increasingly being required to do. Knowledge and understanding of learning disability and autism is expanding all the time. We now have a greater number of adults than ever before who, at stages in later life, are being diagnosed as being autistic, and I am quite sure that quite a number of those people have been subject to misdiagnosis. The particular thing that I want to focus on is training for people who are responsible for detention and high levels of treatment. Noble Lords will be aware of the tragic case of Oliver McGowan, a young man with learning disabilities who was inappropriately treated and died. There has been an amazing campaign by his mother to ensure that that does not happen to other people by making sure that anybody who is involved in the provision of mental health services has undergone appropriate training and understands learning disabilities and autism. My understanding from Oliver’s mother is that there are three tiers of training. Tier 1 is a level of training which is required for all people who work generally with people with learning disabilities and autism. They need to have this general level of awareness. Tier 2 is for health and social care staff and others with responsibility for providing care and support for a person or people with learning disabilities or autistic people but who would seek support from others in a complex management and decision-making process. They would be part of a team referring up to others. Tier 3 is specialist training for professionals who have a high degree of autonomy and are able to provide care in very complex situations, which might include people with learning disabilities and autism. The training appears to be sequential. You have to have completed tier 1 training in order to go on to tier 2 and then tier 3. Tier 1 is an e-training module which takes about half a day. As far as I understand it, about 1.5 million people have done that. That is a good thing: we are getting to a greater basic understanding of learning disability and autism by many people across the NHS going about doing their jobs. Tier 2 is a one-day intensive training programme, and that has not gone so well. There have been problems with its implementation, and it is not clear how many people have undergone that training. There are also some quite considerable questions about the quality and scope of that training. Tier 3 is not part of the Oliver McGowan programme, although it is the most relevant to this Bill. As of December 2024, the Department of Health website makes absolutely no mention of tier 3 training at all. Can the Minister tell us where the development of that training is up to, and who is responsible for ensuring that the content of it is suitable? Is it sufficiently developed for people who are having to make very difficult decisions, particularly around detention of people who are quite often in a state of disturbance at the point at which that decision is taken? If we do not follow up on this tier 3 training, then we are going to carry on in the situation where we are now, where we know that people are being wrongly diagnosed by people who, perhaps, should not be expected entirely to understand them because their professional training up to this point has largely not included such people. The noble Baroness, Lady Murphy, and I bow to her superior knowledge, very much made the case to us last week that we are talking about different types of mental disorders and very different specialisms across the mental health services. I am therefore asking that anybody who is in a position of making the decision to detain—and let us remember that people are making decisions to detain not just under the mental health legislation but also, at times, under the mental capacity legislation—should be appropriately trained. That is why I put down my amendment which, I admit, is not perfect, but I hope that the Minister might take some of my point and my intent and that we might take this forward together.

My Lords, I shall speak to my Amendment 42A in this group, which follows on from the two previous amendments from the noble Lord, Lord Scriven, and the noble Baroness, Lady Barker, particularly the details that the noble Baroness has gone into about the need for training and expertise for people who are dealing across the piece with those with autism and learning disability and, importantly, when those clinicians take the decision to admit somebody. As we know, one of the problems that is facing us and why it is so important that these issues have come forward in this particular Bill is because there have been so many inappropriate admissions where people have been detained for so long that it has become a scandal.

17:00:00

In my 32 years, in both Houses, I cannot think how many times I have contributed to debates about the need to release people—to get people with autism and learning disabilities out of the detention in which they find themselves, sometimes for years and years. Each time we have these debates, we say, “We must do something about this”. This is the Bill that can do something about it.

Following on from what the noble Baroness, Lady Barker, has so ably described to the Committee about the tiering of training, Amendment 42A perhaps goes a step further. It would amend the Bill to ensure that one of the two registered medical practitioners who recommend that someone be admitted for treatment is an expert in autism and learning disability, where these are either diagnosed or suspected. It is quite common, particularly with adults, for somebody to be admitted, only for the autism to be diagnosed for the first time in their lives once they are in a medical environment.

It is important that that expertise, specifically from one of the two registered practitioners, is in the Bill. We had a bit of an exchange in last week’s debate about just how expert they need to be. However, I will put on the record my belief that a general psychiatrist—who has not had that specific training and does not have a living, working expertise that involves knowing and understanding people with either autism or a learning disability—will almost certainly make the wrong decisions and, even worse, as I have personally witnessed, the wrong diagnosis.

It is not uncommon—I use the word “uncommon” deliberately—that, when somebody on the autism spectrum is admitted and the diagnosis of autism is either not accepted or not recognised for what it is, they are treated for some other diagnosis: all too commonly, schizophrenia. I have witnessed what then happens when the clinician chooses from a list of medications to treat someone who is not schizophrenic. They try one drug; it clearly does not work; they then try another—and work their way through the list.

I remember a father showing me what happened to his adult son, who was a very able artist. He was misdiagnosed with schizophrenia, and I have seen the paintings that this man produced after somebody had tried to go through the list to find the right drug for him. It is a scandal; that is why I believe that this should be included in the Bill.

My Lords, I will speak to Amendment 33 in the name of the noble Lord, Lord Scriven. If this Bill is a success, we shall, I hope, see fewer people with autism and learning difficulties detained under the Mental Health Act. However, the noble Lord’s amendment goes to the heart of the problem of resources. The current system is broken. It is a market system, which ends up with a lot of people finding themselves detained in facilities far from home, and getting out of that system can be very difficult. The collection of data will be important: first, to find out how many people are being detained. Having spent 23 years in the other place and having been a passionate advocate for mental health, I always found that data is one thing that is never really kept. It is kept between the Department of Health and various other healthcare providers. Getting that visibility for the numbers we are talking about will be very important. We need to be honest that, in the entire mental health debate, people with autism and learning disabilities have been overlooked. To get this right, having proper community-based facilities will be very important, but it will be expensive. The market model we have at the moment means that lots of private companies provide care at very high cost, and commissioners tend to have to commission only from certain providers. This leads to a shortage of supply and prices going up. The Minister needs to spell this out. I understand what the noble Lord said in moving the amendment, but it is important to have visibility of not only the numbers but where the community facilities are going to be. New Clause 125FA(2)(b) in the amendment says the Secretary of State should ensure that community services are available to meet demand after 28 days. If you speak to any commissioner at the moment, they will tell you that that is completely unrealistic. I accept that it was put in the amendment for debate, but that is an aim we should be trying to get to in supporting people in the community. I have seen sad cases of people being stuck in the system. With the best will in the world, and I think there is cross-party support for this, we should not have people with learning disabilities and autism stuck in the system for as long as they are, with no way of getting out. I accept that the Bill aims to give a voice to those individuals, but without the resources to match, they will still go round the merry-go-round of different funders. Another important issue that we need to highlight is the lack of support staff in the community for dealing with people with learning difficulties and autism. That is not seen as a priority at college. We need to put more emphasis on making it an attractive career and on the fact that it is vitally needed and will make a real difference to the individuals concerned. Training is important, but so is getting people into the service in the first place. I accept that the noble Lord is not going to press the amendment, but it goes to the heart of most of the matters in the Bill. We are deluding ourselves if we think the good and well-intentioned things in the Bill will be delivered without the resources to do so; they will not. The one without the other will lead to people still being detained when, in a modern society like ours, they really should not be.

My Lords, I give my strong support to the noble Lord, Lord Scriven, asking for a road map, which I think is the political phrase we use now, to get to where we want to be. I remind him that, back when the then Government came in in 1987, we had a documented timetable for closing the learning disabilities hospitals but that never happened; it went too slowly. So, we have left people stranded in various independent sector and NHS facilities, partly, to be honest, because the Department of Health took its eye off the ball as to what was happening to people in long-stay care and just stopped looking. So I agree that we need some kind of timetable; otherwise, the Bill becomes simple aspirations, as we have already said. Unfortunately, it is not just autism and learning disabilities that require special training. In a lot of areas of mental disorder, people get inadequate training in subspecialties when they are studying the general psychiatric stuff. Psychiatric nurses do not get enough, either. I agree that there are issues here that require a special target, but at the moment they do not get it, so I support that as well. On the experience of the noble Baroness, Lady Browning, of course it is true that there are an awful lot of bad psychiatrists around. There are bad physicians and bad surgeons—not the noble Lord, Lord Kakkar, before he punches me on the chin. We should not say “bad”; I would say “not the best”. A friend of mine was visited by a community psychiatrist in old age psychiatry about a month ago. I asked his partner how it went, and he said, “Well, he was in and out in 15 minutes. He’d got 10 assessments he was going to do in people’s homes around south Norfolk in that time”. That was a totally inadequate amount of time to get a history from relatives, to get an understanding of what was going on in the home situation and to understand the problems this person was experiencing. I was shocked, but I was told not to be because it happens all the time that there is an inadequate length of time for people’s assessment. It is hardly surprising that diagnoses are wrong and that people end up with the wrong prescriptions. It is deeply regrettable, but this will happen for as long as community services are underresourced. As we have heard from all around the Chamber, you can put as much in place as you like, but if it is underfunded, has the wrong facilities or is too far away from where people live, it just will not happen. We need a road map, and we need to know when these facilities will be made available, because the rest of it cannot happen until they are.

My Lords, I will speak to my Amendment 152. We have already had a rich debate, concentrated on certain areas. This amendment deals with a somewhat different area, which is why I wanted to include it at the end. We have talked quite a bit about training and research and the link between the two. The noble Lord, Lord Scriven, said in introducing this group that it was all about autism and learning difficulties, but this amendment also covers mental health, for the interests of clarity. This is a probing amendment, but there is an argument for doing what it calls for, which is having a report to Parliament, two years after the Bill is passed and then every three years thereafter, about the provision for and progress in research, and the transfer of research findings, in mental health and autism and learning difficulties. This would enable Parliament to keep a check on how much resource is being put into this area and, crucially, how much knowledge is transferred into practice. It would also be a really useful tool for informing Parliament about what is an extremely fast-changing area. It is worth noting that mental health and disabilities are areas in which research is not just redefining our understanding but often entirely demolishing old models and forcing a restart from the basics. We are also seeing a change in approach, in which I am very pleased to say that there is an increased focus on ensuring that experts by experience can guide and have input into research directions in a way that certainly was not true in the 20th century. I note, for example, an interesting study from the University of Stirling last year, which spoke to people in Scotland—though I have no doubt this applies more broadly. It looked at how research in autism currently tends to be directed towards biological studies and a search for treatments and cures, but autistic people said that they would prefer a focus on a good quality of life, and that they should have a real say in the research directions. They were concerned that continuing even now are ableism, objectification, and other othering approaches in research directions. I spoke on the previous day in Committee about the failure to apply the social model of disability to learning difficulties and autism. That is very much the case. I hope that that will change, which would change what we should be researching and how we should be training people. Moving to perhaps more comfortable ground for many people, I note that there is a replication crisis across many areas of research. That is particularly true in the mental health space, where, unsurprisingly, there has been a recent dawning that conducting a great deal of research on US college students does not necessarily produce findings that can be replicated all around the world in all sorts of different research conditions. For example, with Alzheimer’s disease, are amyloid plaques a cause, a symptom or simply correlated? I have no idea, and I doubt that anyone can say, with their hand on their heart, that they know either. This an area in which the continuous failure of medical trials has shown our lack of knowledge.

17:15:00

Just this week, an interesting study in Translational Psychiatry found a very close link between the bacteria in our mouths and mental health. I spoke at Second Reading about the gut-brain axis, and these researchers are talking about the oral-brain axis. Their analysis found notable differences in the composition of oral bacteria, suggesting that the oral microbiome may play a significant role in mental well-being.

Last year, there was a study in the UK on avatar therapy for people who hear voices, also known as auditory hallucinations. That was said to provide potentially life-changing results for people with psychosis. It could reduce both the voices heard by an individual and the distress that these voices can cause. This is interesting, breakthrough research, using a different kind of technique that someone who was trained 20 or 30 years ago is extremely unlikely ever to have been exposed to—we would hope that they are keeping up, but there is so much out there from so many different directions.

This amendment aims to ensure that, given that we have brilliant researchers making real progress, Parliament knows about that, it is incorporated into treatment, and we are really keeping up. As we heard earlier in the debate on this group, we are not at the moment.

My Lords, I want briefly to make a couple of comments on this important group. As everyone has acknowledged, an absolutely vital change to the Bill is that, in the future, people with learning disabilities and autism will not be detained by the Bill and their needs are to be met in the community. I am sure we can all agree on and gather around that. The noble Lord, Lord Beamish, made the point that, far too often in the past, people with learning disabilities and autism have been overlooked. I see the Bill as a real opportunity to do something substantive about that. That is why I note some of the amendments we have heard about in this group—certainly those in the names of my noble friends Lord Scriven and Lady Barker, and others—about the importance of having properly trained staff with up-to-date knowledge and expertise, as the noble Baroness, Lady Bennett, has just mentioned. For any of this to happen, it is important that there is a proper plan, that is costed; the resources need to be available, and properly trained staff with up-to-date expertise need to be available in the community. To ensure that there is some sort of accountability around all this, I reiterate the question that my noble friend Lord Scriven asked the Minister: when will we see new targets—we have not got any at the moment—to reduce the number of detentions of people with learning disabilities and autism? It would be helpful to know that those targets will be put in place and that there is some way of monitoring the progress on all the important things we have been talking about in this group.

I agree with what has been said: we need a definitive plan for how things will work out. We cannot rely on it being in five or 10 years because, as the noble Baroness, Lady Murphy, said, it then just becomes an ambition rather than a target to achieve. I support the amendment of the noble Baroness, Lady Browning, which strongly asks that the people who look after children with autism and learning disabilities are properly assessed by properly trained and accredited people. We know that, currently, children are ending up in detention inappropriately because they are assessed to have a psychiatric condition such as schizophrenia—as the noble Baroness, Lady Browning, said—when, although they might have some psychiatric sub-condition, they fundamentally have autism or learning disability problems. I am sorry that the noble Lord, Lord Adebowale, is not here to speak to his Amendment 150, which asks quite powerfully for a clear plan to be laid out, with resources tied to it, to achieve the ambitions there are in the Bill. I would have supported his amendment probing the Minister as to how resources will be allocated to achieve the ambitions for those targets to be met.

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.

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.

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.

17:30:00

I understand the concerns behind the amendment, emphasised by the noble Baroness, Lady Tyler, and the calls for, and the importance of having, a clear plan for resource allocation and service provision—these have been broadly emphasised in the course of the debate. The plan referred to will form part of the items that support the Bill, through an implementation plan, but due to the uncertainty around future funding arrangements, we do not think these amendments will meet their intended purpose. This amendment could, for example, force the government and/or local areas completing their planning processes to set out unfunded or somewhat speculative plans ahead of any funding settlements, and, as such, those plans would lack credibility. I suggest to noble Lords that it would be more effective to set out plans when they are ready, as opposed to following a somewhat arbitrary timetable set out in legislation.

The noble Lord, Lord Scriven, asked about upfront funding and the references in the impact assessment, and the timing of policy changes. The timing of the policy changes is illustrative; it is for modelling purposes, to give us the firmest baseline data from which to model the costs associated with the reforms.

Updating our assumptions on the number of autistic people and people with a learning disability who may require detention under this Act within the amendment’s four-month timescale is very unlikely to yield different figures from those in the impact assessment that has already been published. We simply do not expect that there will be significantly different data in this timeframe, which relates to the point raised by my noble friend Lord Beamish. While I understand the need for pace, it is also about getting it right.

I must also stress that sufficient community services for autistic people and those with a learning disability cannot be achieved without wider system reforms that go way beyond health. As such, the details in any plan have to be considered in the context of the 10-year plan, which is ongoing and in its consultation phase. We are also looking forward, of course, to the commencement of the independent commission into adult social care to be chaired by the noble Baroness, Lady Casey.

I gently remind noble Lords that we will have the opportunity to discuss implementation more fully as part of a wider discussion in a later Committee session, but, in my view, this is a helpful discussion because I am sighted on areas of legitimate concern raised by noble Lords. My officials will be engaging with expert stakeholders and other government departments to ensure that there are robust plans being developed and subsequently put in place. While I cannot commit to specific timeframes for publication, I am happy to keep the House updated, and I know the House will continue to give proper scrutiny to this matter.

I now turn to Amendment 34, tabled by the noble Baroness, Lady Barker, on the topic of mandatory training in diagnosis and treatment of autistic people and people with a learning disability for those who have treatment and diagnostic responsibilities. Like the noble Earl, Lord Howe, I agree that it is essential that professionals have the skills and knowledge to make an informed diagnosis so that appropriate care and treatment are provided. The Health and Care Act 2022 requires that all CQC-registered health and adult social care providers ensure that their staff receive specific training on learning disability and autism. As the noble Lord, Lord Kakkar, said, this training must be appropriate to the staff member’s role, to help ensure they have the right knowledge and skills to provide safe and informed care. While understanding the intention, we believe that the amendment is unnecessary, given the existing statutory requirement on health and care professionals that exists in other legislation.

The noble Baroness, Lady Barker, raised a specific point about specialist training, asking where the development of training was up to and who is responsible for ensuring its content. Providers are responsible for ensuring that staff receive sufficient training that is appropriate to their role, and that may well mean additional training beyond the Oliver McGowan mandatory training on learning disability and autism. As we know, additional training may come from a diverse range of sources, including, for example, training on child intellectual disability psychiatry or overmedication. NHS England is rolling out a national autism trainer programme in mental health services, and it commissioned the Royal College of Psychiatrists to deliver the national autism training programme for psychiatrists. That will reduce diagnostic overshadowing and it is intended it will play a significant role in preventing unnecessary admissions for autistic people to mental health hospitals and improve appropriate care for those with autism—I share concern about this important matter.

This is a key point for a lot of the amendments that noble Lords have asked about. Can the Minister write to all noble Lords with more detail of the training programme—its content, the timetable, who is going to be responsible for making sure that it is implemented and reviewed? Will she specifically deal, in that letter, with my question about whether tier 3 training is included?

I would be very pleased to write to noble Lords, as the noble Baroness suggests. Amendment 42A, in the name of the noble Baroness, Lady Browning, which the noble Lord, Lord Kakkar, also spoke to, relates to appropriate expertise in learning disability and autism for medical practitioners with responsibility for recommending admission for treatment. We strongly agree with the principle of this amendment. The current code of practice sets out that, where a patient is known to belong to a group for which particular expertise is desirable, at least one of the professionals involved in their assessment should have expertise in working with people from that group wherever possible. The code also makes clear that consideration should be given to any disability the person has in order that the assessment has regard to that in the way that it is carried out. The noble Baroness, Lady Browning, asked further about how the Bill will make sure that professionals have the right skills and expertise. This whole area rightly comes up repeatedly when we debate. I accept that it is crucial that those with a learning disability and autistic people are dealt with sensitively and professionally. It is crucial that clinicians are able to make distinctions between a learning disability or autism and any co-occurring mental health disorder—that point was made powerfully. It is a matter for clinical judgment to determine whether a person with a learning disability or an autistic person meets the criteria for detention under Part II, Section 3 due to a co-occurring psychiatric disorder. To assist clinicians in decision-making, we will update the code of practice to provide the guidance that will be necessary, and I hope that that will make a major change.

I am grateful to the Minister and very encouraged by her response. I want to flag up something else that I raised. Occasionally, at some point of crisis for undiagnosed adults, the question is asked: could this be autism? At that point, we need people who have a very good working knowledge for them to raise that question, because it can make a world of difference if they are right. It is not just about somebody who presents with a diagnosis; it is about those who are undiagnosed. I do not know the quantity, but my gut feeling is that there are quite a lot of adults out there who are still undiagnosed. I do not know how the Minister will accommodate that situation.

The noble Baroness makes a good point. Indeed, not everybody has a diagnosis. I suggest that, when we look at provisions, we should make clear—through the appropriate means and not in primary legislation—how the practice should take account of the point that she made very well. I will be extremely mindful of that. We believe that the code of practice is the most appropriate place to articulate the type of experience that might be required in this area, through a non-exhaustive list of practical examples, which would avoid the need to define in primary legislation exactly what constitutes sufficient experience. The reason for that is to allow flexibility on the particular needs and circumstances of the individual. As we update the code of practice, we will engage with expert stakeholders to improve practice and to reflect the new Act. The code will be laid before Parliament before its final publication. I thank the noble Baroness, Lady Murphy, for her comments in this area. The number of long-term detentions was rightly raised by my noble friend Lord Beamish and the noble Baronesses, Lady Murphy and Lady Browning. The number of people with a learning disability and autistic people in mental health hospitals is indeed unacceptable. Too many people are still being detained who could be supported in their communities with the right provision. Work is under way to address this. For example, NHS England has allocated £124 million of transformation funding for services, which includes funding to reduce reliance on mental health in-patient settings. Noble Lords can be reassured that I will take a particular personal interest in this area.

On that point, I welcome what my noble friend the Minister has announced, but the real problem is about housing, including specialist housing in different areas for individuals leaving secure units. That is not universal throughout this country, as people leaving mental health units are then having to travel long distances. Surely we need local plans, and that money going in locally to provide the housing needed.

My noble friend makes a good point about housing; we discussed it on day 1 in Committee. We are working with our ministerial colleagues who deal with housing on the need for the right kind of housing to be available. The point was well made and is taken.

17:45:00

Amendment 145, in the name of the noble Earl, Lord Howe, and supported by the noble Lord, Lord Kamall, relates to a review on mandatory training for professionals with responsibility for treating people with a learning disability and autistic people under the Mental Health Act. We absolutely recognise the importance of monitoring the training that staff undertake. For example, I am pleased that a long-term evaluation of the delivery and impact of the Oliver McGowan mandatory training has been commissioned. As noble Lords may know, this training has been developed and rolled out to support providers to meet the Health and Care Act requirement that I referred to earlier. The findings of the evaluation, taking place over three years, will be a great help to us in understanding how it has been implemented and its impact, because there is a lot of reliance on, as well as reference to, that training.

The Health and Care Act 2022 requires the Secretary of State to issue a code of practice to guide providers in meeting this training requirement, and legislation already requires the code to include information on monitoring and evaluation. The Health and Care Act 2022 requirement builds on existing responsibilities, and ultimately requires providers to determine what training is appropriate for their staff and to provide such training, given their role. The broad scope of this requirement, and the wide range of staff roles and care settings, means that the training undertaken to fulfil it could be highly varied and could differ from person to person. That gives rise to practical challenges for monitoring compliance.

As we seek to address this, we also want to guard against creating something of a “tick list” of required training, which would, inadvertently—I stress, inadvertently—undermine responsibility for determining appropriate training. It is also important to note that, when assessing services, the CQC will check whether the Health and Care Act requirement is being met and may take action if it is not. Given the range of activity already under way, and while we understand what lies behind the amendment, we believe that it is not required.

Finally, Amendment 152, tabled by the noble Baroness, Lady Bennett, would require regular reports to be published on the resources available to support research into mental health care for autistic people and people with learning difficulties, including those who may be detained under the Mental Health Act, and on the adequacy of training for staff in new approaches to mental health care for those groups of people. I agree with the noble Baroness that these are important matters, because we need to be able to update and improve practice as the evidence base develops.

The department invests in research through the National Institute for Health and Care Research, which welcomes funding applications for research into any aspect of human health and care, including on the mental health care of those with learning difficulties and autistic people. Those applications are subject to peer review and judged in open competition, and awards are based on the importance of the topic to patients and health and care services, as well as value for money and scientific quality.

There would be a welcome for applications relating to learning difficulties and autism in respect of NIHR programmes, which would enable maximum flexibility both in the amount of research funding a particular area can be awarded, but also the type of research that can be funded. Information on this is on the NIHR website.

I understand that the Minister may wish to write to me on this, but I wonder whether there is a real prioritisation of those experts by experience guiding that research, and what input there might be. If the Minister can write to me, that would be fine.

I would be pleased to write to the noble Baroness. As I set out in response to other noble Lords, I hope the Committee has heard how much I agree that the adequacy of training is a key issue. We are aware that developments in best practice in caring for people with a learning disability and autistic people need to be reflected throughout. As I set out, the Health and Care Act 2022 requires that staff be given the training appropriate to their role, and we expect that this should be reviewed in line with the up-to-date situation. The CQC assesses staff training as part of its regulatory function. For these reasons, I ask the noble Lord to withdraw his amendment.

My Lords, I thank noble Lords who have taken part in this useful and informative debate, and I thank the Minister for a thorough explanation of what happens. However, there does seem to be a disjoint between what is happening on the ground and what people in an office in Whitehall seem to think is happening. That is why noble Lords have discussed issues to do with data, training, a costed plan, research and development, and the implementation of people who at least have training and an expertise in diagnosis. Something just does not feel right. The Minister has explained what is happening, but without a fully costed plan up front, with targets, accountability and data ongoing, what will happen is what happens now. Things will be diverted and diluted, and we will not be able to hold the plan to account. For that reason, while I thank the Minister for the explanation she has given, I feel that we will return to this issue at a later stage to dig down and get that deliverable framework. In the meantime, I beg leave to withdraw my amendment.

Amendment 33 withdrawn.

Amendment 34 not moved.

Clause 4, as amended, agreed.

Amendments 35 to 37 not moved.

Clause 5: Grounds for detention

Amendment 37A

Moved by

37A: Clause 5, page 11, leave out lines 14 to 16 and insert— (b) there is a risk of serious harm to the health or safety of the patient or of another person;”Member's explanatory statement This amendment and others in the name of Baroness Murphy remove from the criteria any mention of “likelihood” or “may be caused” and replace them with wording that allows a clinician to evaluate risk in the individual case and give evidence more straightforwardly and comprehensively without making predictions for individuals about risk.

My Lords, in this group, we return to the issue of serious harm and risk. Clause 5, on the grounds for detention, implies that the risk factors for detention under Part 2 are identifiable and that risks are readily assessed. A number of clauses in the Bill are all about the same thing, which is why there are so many amendments in this group. They imply, again, that risks are quantifiable and predictable—if only. Academic research has often stressed how difficult it is to predict episodes of violent behaviour in individuals, because they are rare. Risk assessments given as likelihoods are of limited use when the base rate for violence in a population, particularly serious violence, is low. The same is true, by the way, for suicide and suicidal thoughts. It has been calculated, using the average of all the current tests and rating scales that have been carefully assessed in research studies, that if 5% of the patient population were in a high-risk category, the tests would correctly identify eight in 100 people who would go on to commit acts of violence, but misidentify as violent another 92 people. In fact, less than 1% of community patients will commit serious violence over the period of a year, which means the tests would correctly identify only three patients out of 100. Homicides occur at a rate of one in 10,000 patients suffering from a psychosis per annum, which makes prediction more or less impossible. A number of factors are statistically associated with later violence at a group level. Even the most effective predictive combinations of variables constructed by statisticians perform poorly, except at group level. So making statements about individual risk based on the use of these tools is complex, and some would say unsafe and unethical. Structured risk-assessment systems can be useful in routine clinical practice; indeed, most people use them in day-to-day team thinking about what these risks are. When employed by staff properly trained in their use, they are useful pointers. They perform better than unaided clinical judgment in predicting future violence, but again, at a group level. On an individual level, these checklists need to be part of a detailed understanding of a patient’s mental state, life circumstances and thinking, which is a major contributor to the prevention of harm. This is best achieved, as always, by well-trained professionals operating in a well-resourced environment where staff know well the patient’s history, response to treatment and life circumstances. The wording of the Bill encourages pseudo exact probabilities and predictions of individual behaviour, which are not possible. This exerts pressure on psychiatrists, particularly at tribunals, to make predictions that may be seriously wrong. Unreasonable expectations of what can be predicted lead to defensive practice—to detaining people where it is not justified by the unreliable evidence. There are several places in the Bill where the impression is given that risks are reliable and predictable, but it is not so. As I say, the same problem arises with suicide and suicidal behaviours. I ask the Government to look at whether the wording of these clauses is reasonable, given the evidence, and to substitute these certainties with something more flexible, indicating that a more rounded, holistic and comprehensive assessment is necessary. I beg to move.

My Lords, I rise to speak to Amendments 86 and 67, in my name, in this group. I put them in that order as Amendment 86 more naturally follows on from—

Wrong group.

Apologies.

I am awfully sorry, but I should have mentioned that I also have almost all the other amendments in this group. They cover the same question—it is just about the wording of these two phrases. Amendment 45, along with one other, is not mine, but most of the amendments are covered by those brief words.

My Lords, I think that I am speaking in the right group. Amendments 45 and 48 are in my name, and although they are in this group, they are of a rather different nature. They are about the framework and definition of “appropriate medical treatment”. I will briefly outline the overall context and why I thought it important to bring these two amendments forward. I am particularly concerned that many in-patients in mental health hospitals, particularly autistic people and people with a learning difficulty, continue to face detention in hospital settings which can provide little or no therapeutic benefit. The environment of these hospital settings can be incredibly overstimulating and distressing. We continue to hear stories of restrictive practices, including physical, mechanical and even chemical constraint, as well as the use of solitary confinement.

18:00:00

It is a clear principle of the Bill that any detention in a mental health hospital must have therapeutic benefit—I think we are all agreed on that. Everyone is different, and whether detention has therapeutic benefit for a person must be assessed by seeing them as an individual and understanding them as a whole person. The purpose of Amendment 45 is to clarify that the definition of “appropriate medical treatment” introduced in new Section 1A includes consideration of the setting in which treatment takes place.

Placing this wording in the Bill will ensure that the hospital environment is taken into account when deciding whether appropriate medical treatment can be delivered. Too often, the appropriateness of the hospital environment—as I have said, particularly for autistic people and people with learning disabilities—is not given primacy in decision-making or, frankly, considered at all. Reviews of the use of restrictive practice in hospitals have concluded that many ward environments are chaotic and non-therapeutic, and often trigger behaviour that necessitates the use of segregation and restraint. This can then lead to further behaviours that challenge and cause a decline in mental health, meaning that the person does not get better, which is what we are all looking for, but ends up being hospitalised for what can feel like a very long time indeed.

In-patient wards can be particularly distressing environments for autistic people, and often environmental problems—basic things such as noise, echoes and harsh lighting—can adversely impact on therapeutic benefit. Where that environment is not therapeutic, it may mean that people are less likely or willing to engage with therapies. In some cases, although a particular medication may be considered clinically appropriate, the distress that can be caused by being contained in a mental health hospital may mean that the benefit of that therapeutic intervention is undermined by the hospital environment, and therefore detention in hospital can easily have a negative impact on a person’s well-being. It is vital that these environmental factors are considered, particularly, as I say, in relation to adults with a learning disability or autism, where even very small changes in everyday routines can be incredibly distressing.

The NHS England guidance for commissioners states:

“For people admitted to an acute mental health unit, a therapeutic environment provides the best opportunity for recovery”.

The guidelines go on to talk about the attention that needs to be paid to specific environmental factors which can increase the risk of challenging behaviour. It is important that all these points are considered when deciding on whether appropriate medical treatment would have a therapeutic beneficial impact. We need to recognise, as I am sure that we do, that everyone is different. The right environment can be based on a person’s own sensory profile, and that sensory profile can change throughout someone’s detention in a mental health hospital.

The report of the independent review, which we have talked about so often, stated that therapeutic benefit

“should not be limited to any treatment they receive but must also cover the social and physical environment of wards”.

This is particularly important given the dilapidated condition of much of the mental health estate, which needs urgent attention and capital investment. When we talk about parity of esteem between physical and mental health, what message does it send that the mental health estate is always at the end of the queue?

Briefly, Amendment 48 would ensure that the definition of “appropriate medical treatment” has regard to the principle of therapeutic benefit established in the Bill, which addresses the effectiveness and appropriateness of treatment. Therapeutic benefit is one of the four principles underlying the Bill, which are all identified in the independent review. Despite the importance of ensuring that therapeutic benefit guides many of the important changes that we are talking about in the Bill, as currently drafted the words “therapeutic benefit” are found only once, to be inserted in Section 118 of the Act to ensure its inclusion in the code of practice, alongside other principles.

At present, the definition of “appropriate medical treatment” includes no specific mention of therapeutic benefit. My contention is that therapeutic benefit should be the fundamental principle upon which appropriate treatment is defined, thus the importance of its insertion in this definition, to bring it in line with the spirit of the Bill. This change would ensure a proper recognition that patients are supported to recover so that they can be discharged from detention at the earliest convenience and not end up stuck in wards where there is little to no therapeutic input, meaning that discharge is continuously delayed due to a lack of progress.

We hear stories about autistic people and people with a learning disability being stuck on wards for an average of nearly five years, where they face being overmedicalised and institutionalised, sometimes to the extent that they can barely get out of bed. These detentions lead to severe lifelong trauma, which can be incredibly difficult to overcome. This leads to an obvious risk of readmission after they are discharged into the community. I feel this is little short of—to use the phrase that the noble Baroness, Lady Browning, used—a human rights scandal, and it has to end. I believe that an explicit focus on therapeutic benefit when delivering treatment is one way that the Bill can help to achieve that. We simply must grab hold of this opportunity.

My Lords, given that all those who have spoken to this group of amendments have been brief, I shall try to be brief. Once again, I thank the noble Baroness, Lady Murphy, for discussing with me in an exchange of emails over the weekend the intent behind the amendments in her name. The noble Baroness, Lady Murphy, makes a reasonable point about clauses in the Bill that contain the phrase “likelihood of the harm” or “serious harm may be caused”, because it is assumed that such risks are quantifiable and predictable. I was struck by her observation that psychiatrists, psychiatric nurses and academics have warned about the difficulty of being able to predict episodes of violent behaviour in individuals because the base rate for violence, particularly serious violence, in the population is low. One of the things that we keep saying throughout this debate is that we need to see the evidence and the data, and that that should drive decisions that are being made. Given that, I am grateful to the noble Baroness for sharing the statistics, which I will not repeat but which reinforce the point that she wanted to make. Considering those statistics, I am sympathetic to two specific points that the noble Baroness made. The first is that making statements about individual risk based on such statistics is complex and possibly unsafe, and, as the noble Baroness said, may be unethical. The second is that it may be helpful to use structured risk-assessment systems in routine clinical practice, if used by appropriately trained staff, to predict possible violence at a group level. However, given that many noble Lords have spoken about patient-centred care and the importance of understanding the individual and their sensory profile, surely we should be looking at patients as individuals, where the clinician better understands the individual patient’s mental state, relevant history and response to treatment given his or her life circumstances. I will be interested in the Minister’s response to the amendments in the name of the noble Baroness, Lady Murphy, urging the Government to replace wording such as “likelihood of the harm” or “serious harm may be caused”. These terms are inexact and somewhat ambiguous and do not appear to be driven by evidence. Perhaps there are more appropriate terms for more holistic and comprehensive assessments. Amendment 45, tabled by the noble Baroness, Lady Tyler, proposes that the definition of appropriate medical treatment includes the setting in which treatment takes place. This takes us back to a point made on the first day in Committee by the noble Baroness, Lady Barker, and just now by the noble Baroness, Lady Tyler, that for those with autism and learning disabilities, being held possibly in noisy, bright, busy settings full of people who may be strange to them, and where they may feel powerless and worry about what will happen next, is likely to affect their mental health and well-being. Therefore, surely it is important that we take account of the points made by the noble Baronesses, Lady Barker and Lady Tyler, particularly in Amendment 45. On Amendment 48, it is really important that care is led by the level of therapeutic benefit. That should be based on evidence to drive those decisions. Given that, I look forward to the Minister’s response.

My Lords, I am most grateful for the contributions that have been made and the amendments that have been tabled. I turn first to Amendments 37A, 37C, 38A, 38B, 42B, 42D, 42E, 42G and 42H, all tabled by the noble Baroness, Lady Murphy, and spoken to by other noble Lords, including the noble Lord, Lord Kamall, regarding the new criteria. Let me say at the outset that the new criteria explicitly require decision-makers to consider the risk of serious harm and the likelihood of those harms occurring in order to justify detention. Clearly, the reason for this is to ensure that any risks to the public and the patient are consistently considered as part of the assessment process, and to protect patients from lengthy detention when these risks are unlikely to occur. I hope that this will be helpful for some of the debate that we have had. The amendments tabled by the noble Baroness, Lady Murphy, seek to revise the proposed new risk criteria to remove any mention of risk that “may be caused” or the “likelihood” of the risk transpiring. The purpose appears to be to remove any prospective assessment from the detention decision and instead focus on the risk as it can be established at the time. The noble Baroness, in her introduction, asked about the reasonableness of the words in the provisions, and I understand that this is where the concerns lie. I should also thank the noble Lord, Lord Kamall, for his comments on evidence and data and their importance. In answer to the noble Baroness, I should say that the independent review found that the current criteria for detention are too vague and recommended that the Government should update the detention criteria to be more explicit about how serious the harm has to be and how likely it is to occur to justify detention. The intention of the revised detention criteria in the Bill is not to ask clinicians to make predictions but to clarify that they should consider whether a harm is likely to occur, based on their assessment and knowledge of the person—something that the noble Lord, Lord Kamall, focused on—rather than based on risks which may never occur. Any consideration of risk arguably preserves the need to look at what might happen rather than what is happening or has happened in more concrete factual terms. We think that it is important that the detention criteria allow clinicians to detain based on the risks that they think are likely to happen, rather than just the risks that have already materialised. This enables them to act early to prevent harm to the patient or others. In line with the intention of the noble Baroness’s amendments, this should be based on personalised individual risk assessments and information about the patient’s history and personal circumstances—again, something that I know noble Lords are exercised by, which is about the individual approach to this. We did engage again on the changes to the detention criteria last summer, in light of the recommendation on this issue by the pre-legislative scrutiny committee, and to assure ourselves that the detention criteria struck the right balance between allowing clinicians to continue to take early action when they are concerned about a patient’s or others’ safety and the independent review’s concerns that people could be detained on the basis of risks that might never occur.

18:15:00

Taking into account the recommendation of the pre-legislative scrutiny Joint Committee, we have removed the requirement from the draft Bill for clinicians to consider how soon harm may occur, to avoid suggesting that harms must be imminent—and to ensure that we do not dissuade clinicians from making beneficial interventions at an earlier stage. The timeframe in which harm may occur may still be relevant to detention decisions and we will clarify this further in the code of practice.

Amendment 45, tabled by the noble Baroness, Lady Tyler, would require a clinician assessing what constitutes appropriate medical treatment to take into account the setting in which the treatment is to take place. The noble Baroness asked about how it is ensured. I take her point about in-patient wards for people with LDA not undermining the aim of therapeutic benefit. I will be very pleased to write to her on that. This is a very important area, and I want to ensure that I have the opportunity to reflect properly on that and to offer comment on the mental health estate—again, points that were well made.

Before I continue, on the estate and capital investment, I hope noble Lords noticed that the settlement in terms of moneys allocated to the department did include a specific investment in capital to reverse a trend of capital underinvestment over the last 15 years, which was identified by the noble Lord, Lord Darzi, in order that we can start—I emphasise “start”—reducing the backlog of critical infrastructure across the NHS estate. We will be setting out plans for mental health funding in 2025-26 in due course.

Returning to the points raised by the amendment, I should say that Clause 8 embeds the principle of therapeutic benefit into the Bill by providing a new definition of “appropriate medical treatment”. It introduces the requirement that detention must have a “reasonable prospect” of benefiting the patient, and we would expect the setting in which someone is going to be detained to be part of this. The current code of practice already states that patients should be offered treatment and care in safe, supportive and therapeutic environments. We will ensure that this is reflected in the updated code of practice.

Amendment 48, also tabled by the noble Baroness, Lady Tyler, would insert a specific reference to the principle of therapeutic benefit into the definition of appropriate medical treatment in Clause 8. We strongly support the principle of therapeutic benefit and have explicitly set this out in the Bill, as well as embedding all four principles from the independent review throughout our reforms. The changes made to Clause 8 in the Bill already embed the principle of therapeutic benefit in the definition of appropriate medical treatment by introducing the requirement that treatment has a “reasonable prospect” of benefiting the patient to be deemed appropriate.

With that response, I hope that the noble Baronesses will not press their amendments.

I thank the Minister for her response. I have to say that psychiatrists remain worried about this and the possibility that they will be expected to make decisions on risks which they are simply not capable of doing. But I would not want there to be a feeling around that we want to discourage people from taking action much earlier than they sometimes currently do, because, in my view, they often leave it too late before they admit somebody—we have seen a number of such cases recently. I reserve the right, perhaps, to come back with some alternative ideas, but I beg leave to withdraw my amendment.

Amendment 37A withdrawn.

Amendment 37B

Moved by

37B: Clause 5, page 11, line 16, after “detained” insert “by a constable or other authorised person” Member’s explanatory statement This amendment and others in the name of Baroness May seek to introduce a new category of “authorised person” who can carry out detentions under the 1983 Act to offer better inter-agency response. The proposed amendments would remove the need for the presence of police at mental health incidents in the absence of any risk.

My Lords, the amendments in this group standing in my name, Amendments 37B, 38C, 42C, 42F and 128B, are all intended to widen the definition of those who can attend a mental health incident and act to detain an individual in a variety of circumstances. It is a pleasure to speak after a number of noble Lords who have a considerable wealth of experience on the issues in this Bill. I can claim no such breadth of experience, but the amendments I have tabled speak to one issue, which I have dealt with in the past: that of who can attend a mental health incident and particularly the attendance of the police at such incidents. Back in 2010, it became clear to me, as I spoke to more and more police officers in my role as Home Secretary, that there was one issue that was at the forefront of their mind, and it was the problem they had in dealing with people at the point of mental health crisis. Their concern was understandable: they had no training in mental health, they were not professionals in this area, yet they were being called out to situations. They were being expected to determine whether someone was at the point of crisis or not, and what should happen to that individual; more often than not that meant taking that individual to a police cell as a place of safety. For the police officer, there was concern that they were being asked to deal with something for which they had no training or knowledge. Of course, the police presence was often not good for the individual concerned. Inevitably, it meant they were not being given the healthcare support they needed at that point in time; but more than that, the very essence of a police presence—somebody in the uniform coming to deal with them—could actually exacerbate their mental health situation, and a police cell is not designed to improve somebody’s mental health. Finally, for the police force, of course, it meant that it was taking up resource which could have been used elsewhere, and which was, in many cases, inappropriate; often if somebody was in a police cell as a place of safety it meant that an officer had to sit outside the cell to ensure that they did not harm themselves. The issue of the use of a police cell as a place of safety is dealt with in other parts of the Bill, but they do not deal with this wider question of the police resource that is being used. Even if the police are lucky enough to get somebody to a hospital, they still could have to have an officer in A&E sitting with the individual to make sure they do not harm themselves or cause harm to others. Indeed, the Metropolitan Police, in its evidence to the Joint Committee on the draft Bill, cited a case study where a patient was required to be guarded by the police in A&E to prevent them becoming a high-risk missing person, and eight Metropolitan Police officers had to attend that individual for over 29 hours. Police officers were worried about the job they were doing, the individual concerned was not being treated or dealt with in the way that was appropriate for their mental health needs, and police resource was used unnecessarily. Over the years, I and others have tried to address this situation, initially with some success. But what often happens in government, as noble Lords and the Minister will find over time, is that an initial success is turned back because over time people revert to the previous behaviour or mode of operation. That is what we have seen in this case, and it came, of course, to the point where the Commissioner of the Metropolitan Police said that the force would not give an ultimatum and would not turn up to these mental health incidents. As drafted, the Bill has the capacity to at least maintain, if not exacerbate, this problem, but the Government could accept amendments or amend it in a way that would improve the situation. I should say that, of course, if there is an immediate risk to life or serious injury, the police will always have a role to play; but they are clear that they want to see mental health repositioned as a health matter and not seen through the lens of crime and policing-related risk. This is the position that the National Police Chiefs’ Council took in its letter on the Bill to the current Secretary of State for Health, which said: “The current position of the law arguably views mental health through the lens of crime and policing related risk, which raises a number of issues including disproportionality in the criminal justice system, discrimination, adverse outcomes for people suffering with poor mental health as well as increasing stigma attached to mental health”. That concern that the focus and statutory footing of the police as the primary responder to incidents of mental health should be removed from the Bill is what has led to my amendments—it is what they are intended to deliver. I see similarities between my amendments and Amendment 158 in the name of the noble Lord, Lord Davies of Brixton. If I may be so bold, I think we are both trying to achieve a situation where the expected response to someone in mental health crisis is not limited to police; in other words, “right care, right person”. My amendments are intended to widen the description of those who can attend mental health incidents beyond a constable, but they specify that a police officer—the holder of the position of constable under the Crown—can respond if there is a genuine need for a police presence. Recognising that we do not want to see healthcare professionals put at risk, the amendments specify that the authorised person attending an individual should have been “trained and equipped to carry out detentions” and by carrying out that function should “not be put at unnecessary risk”. It is worth noting, perhaps at this point, that the College of Policing’s mental health snapshot 2019 found that almost 95% of calls that police attend that are flagged as a mental health response do not require a police response. I referred to the reasons behind my amendments in relation to the police, but there is support among healthcare professionals for such changes. In the joint Home Office and Department of Health review of Section 135 and Section 136 powers, 68% of respondents to the survey, alongside the review, agreed that all or part of Section 135 and Section 136 powers should be extended so that healthcare professionals could use them provided they were not putting themselves at risk. Paramedics particularly supported the change, with 93.3% of paramedics agreeing and 61.1% strongly agreeing. Beyond the interests of the police and healthcare professionals, of course, we must also remember the interests of the individual at that point of mental health crisis. They deserve the right response, the right care, the right person—and I do not believe that that is always a police officer. This Bill should reflect that and enable a wider range of authorised persons to attend mental health incidents. I beg to move.

My Lords, this is an area where I feel I have the possibility of a solution or part of a solution, while supporting very much what my noble friend has put forward in her amendment. My solution comes from knowledge that we have gained from the world of palliative care. It is a subject matter that we covered in detail on the joint scrutiny committee, because the whole issue of the police turning up to such an incident where somebody is absolutely in crisis can, in many instances, lead only to an increase in the fear and extraordinary pain that that person is feeling when they are in crisis. It is not the fault of the police; it is just the situation that they find themselves in.

18:30:00

Evidence was given to us by Dr Lucy Stephenson and Professor Claire Henderson about an amazing app developed for the world of palliative care that somebody towards the end of their life can have attached to their phone—I believe that in the United States they even have a way of attaching it to a person’s clothing—so that, if they collapse in the street or are in crisis, the app can provide an immediate way for whoever is responding, whatever that person’s position, to find out everything they need to know about that person. It links to the advance choice documents, which I know the Minister knows I have a passionate view on in addition to the need for data on all this.

If an advance choice document in digital form is attached to a person’s mobile in the form of an app, it can show that person’s name, where they live, what their financial circumstances are, which I noticed is in later amendments, what their likes and dislikes are, what their condition is and what their needs are. So, immediately, the person who is helping the person in crisis can be aware that there is an issue and can talk to that person, using their name, and be able to help them in a way that could help to calm them down and take them to the next stage. We even gave a presentation on this to a plethora of officials at the Department of Health and Social Care in March 2023. Several months later, I got a response to say that the palliative care app did not quite work. Of course it did not—it has to be applied differently in order to ask the right questions and give the right information for somebody with mental health issues.

Nothing has happened in developing that app, which is a tragedy because nearly two years have already gone by. It does not require primary legislation, would be inexpensive and could be rolled out across the country in the same way as the palliative care app, which has supported so many people who have been in difficulty in a similar way, by either collapsing in the street or having a crisis in front of a stranger. That stranger becomes almost a friend in that moment by knowing who the person is and how to support them. That is something on which I hope the Minister will have more luck than I did in persuading officials that we can get on and start developing it. There are companies out there. I could give a list of those that could develop this app for the Government and the NHS, which could make an enormous difference to everybody with mental health issues.

Can the Minister also kindly update us on the National Partnership Agreement: Right Care, Right Person policy paper, published in July 2023, which committed to reducing the unwarranted involvement of police in supporting people with mental health needs for all the reasons raised by my noble friend, such as the time, situation and, of course, the extraordinary pressures on police in other spheres.

I make two pleas. First, can we think about an app that could be part of the solution to this? Secondly, can we know more about whether this national partnership agreement is making progress? Both pleas require no change to the legislation.

My Lords, in speaking to my Amendment 49A, I thank the noble Baroness, Lady May, for her amendments. Those of us on the joint scrutiny committee spent a lot of time focusing on the fact that, in truth, a lot of what happens to people who are having mental health crises depends entirely on where they are, who is there and who somebody passing in the street and tries to help them thinks is the right person to call at a moment of emergency. We are all in agreement that the police have for too long been the default answer to a problem but are not the right answer to a problem. The police know they are not the right answer to a problem—I say that as somebody who has lots of police officers in my family. A lot of people having a mental health crisis will end up in A&E just because the lights are on and that is where people go. We are still dealing with one of the problems the Wessely review touched upon, and that is lack of timely access to an accurate diagnosis. My amendment, which I admit was suggested by practitioners in the field, tries to deal with the fact that we do not have an abundance of consultant psychiatrists who are there at the drop of a hat to make assessments. The amendment probes whether we might help things by opening up the eligibility to make diagnoses under Section 12 to people who are health professionals but not necessarily medical practitioners. Back in 2006-07, we had the massive argument about bringing in approved mental health professionals. That was a big battle and there was a lot of rearguard action on the part of consultant psychiatrists, who saw it as a downgrading. Approved mental health practitioners are now very much part of our mental health services and they are a good part of our mental health services. The amendment is trying to open up the making of assessments, simply in order to speed up access to appropriate services. We all understand, and are talking about, the fact that, although we can see the effects of waiting lists and so on on physical health services, waiting lists and the lack of access to appropriate treatment in mental health services are much more hidden. People end up in limbo unless and until there is some kind of outrage, or, to go back to the noble Baroness’s point, until they do something sufficiently serious. We ought to be freeing up the capacity of consultant psychiatrists in particular, because not only is demand growing but there are also particular areas of specialist demand—young people with eating disorders, for example. I frequently hear of worried parents being told that their children are not sufficiently ill to get treatment. They are not alone; there are other people in that same situation. My modest amendment is an attempt to open up and make better use of the skills we have within the NHS workforce.

This is the first time I have spoken in Committee on the Bill, so I declare my interest as a member of the advisory panel of the Money and Mental Health Policy Institute. I shall speak to my Amendment 158, which, as the noble Baroness, Lady May of Maidenhead, said, covers essentially the same ground as hers, and they both aim at the same endpoint. Her elegant and compelling speech has left me in the position of just having to emphasise issues; the case made was compelling, and I hope the Committee will agree. In particular, I hope the Minister will be able to make some sort of positive response. This proposal does not flow specifically from the independent review, but it is in the spirit of what was in that review. The background to the changing nature of mental health services is the significant material increase in the demand for mental health services over the past few years, and the growing number of people on the mental health waiting list or seeking community support. This unmet need has consequences, which are felt by front-line medical staff. My amendment seeks to address that by giving additional powers to paramedics and appropriate mental health professionals. It would extend the reach of Section 136 of the Act, currently confined to constables—or police officers, as I say in my amendment. As previous speakers have said, that needs to be shared more widely. The unfortunate reality of the current situation is that those detained under Section 136 get suboptimal care; we just do not have the resources available for them. There is inadequate provision of suites for Section 136 detention, and there are simply not enough clinicians. We all applaud and support the practice of “right care, right person”, but we must acknowledge that that only increases the demands on the service. The result of all this is that, as we have heard, police officers are taken away from front-line policing duties for many hours. That is bad for everyone involved—for the police officers, for the health service, and particularly for the patients. At the same time, the skills of non-medical health service staff have increased. They are now moving towards the sort of training that equips them to handle such situations. Obviously, giving staff extra powers will not resolve the situation, but we can learn from experience abroad, especially in Australia and New Zealand, where a range of health service staff have a practice called emergency care orders, with the intention of providing greater dignity, removing the sense of criminalisation, and providing appropriate care. As my noble friend the Minister said, what we are looking for is beneficial interventions at the earliest possible stage. A key element in achieving that aim is extending the powers under Section 136 to wider professions. That is not to say that there is no role for police officers—there will always be occasions when their intervention is required—but saying that the single source of entry to services of someone suffering an acute mental health problem is through the intervention of the police is just wrong. There have always been concerns when the powers of medical staff are extended, but this will be an issue of training, guidance and codes of practice—clearly, those will have to be provided—so that the additional powers can be used effectively. To conclude, I emphasise the point that the noble Baroness, Lady May, made in opening the debate. We have moved beyond the point when the powers in Section 136 were essentially about public order—which is, quite rightly, a role for the police. We must ensure that now, commitments under Section 136 are the first stage of a process of medical treatment, in which the unfortunate individual suffering an acute problem with their mental health must be considered first. This is not about public order; it is about appropriate healthcare, where a range of health service professionals can exercise their trained judgment to the benefit of the patient.

18:45:00

My Lords, I support this group of amendments in principle, but I want to make two points. We talk about powers a great deal, but the therapeutic relationship is not about power; it is about collegiate working with patients and users of the service. I appreciate that there are times when we need to intervene when the patient does not want intervention, but we must be careful about the nomenclature as we redraw elements of the Bill. In particular, I welcome the phrase that the noble Lord has just used, which is used so frequently in New Zealand and Australia: emergency care orders. We should think carefully about the fact that what we need is emergency assessment and care orders. People who work regularly with patients over a long period are often the best people to recognise a change in a patient’s behaviour earlier. I fully support the idea that this should be extended beyond police constables, as the noble Baroness, Lady May, outlined, but I also recognise that there will be healthcare professionals, be they psychologists, nurses or social workers, who do not want to take this on. We must make certain that we do not lose some of our valuable team by making it compulsory to take on that extended responsibility.

I shall make a few points in response to the amendments that we have been discussing in this group. The noble Baroness, Lady May, made, very powerfully, an incredibly compelling case. The point she made about police officers sitting in A&E for many hours is so important. Not only is that a waste of police resources, it is often completely inappropriate for the person suffering from acute mental health problems. It can also be incredibly alarming for others in A&E. We all know that, sadly, far too many people are waiting for far too long in A&E, in the sort of environment that is in no way conducive to their overall health, physical or mental. That is my first point. My second point relates to something that the noble Lord, Lord Davies, said. There will still sometimes be a role for police officers. I know from personal experience how much a police presence can be required when a person suffering a very acute mental health crisis is likely to harm both themselves and others. Those others can often be family members who are trying to support the person suffering from the crisis but are also pretty scared for their own safety. It is important that we are talking about widening the range of people who can be that primary responder, but we are not saying that it should never be the police. I agree that if we have a wider primary responder, that individual must be prepared to do it, happy to do it and appropriately trained. We heard a lot in earlier groups about the importance of good training. I was particularly taken with the statistic that the noble Baroness, Lady May, raised about the views of paramedics and how many of them support this, because they are the people right at the sharp end. I cannot quite remember the number who support it, but it was very large, and so I think it is something that we should take seriously. Finally, I want to lend my support to Amendment 49A in the name of my noble friend Lady Barker. Speeding up access to appropriate services is important, as is making the best use of the workforce that we have. For those two reasons, the amendment that my noble friend put forward is important.

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.

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.

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.

19:00:00

To the point about police involvement being stigmatising for those experiencing a mental health crisis, it should be avoided unless absolutely necessary, such as when exercising the powers specific to the police under Sections 135 and 136. The police do not currently have the ability to detain under Sections 2, 3 or 5 of the Act. We do not support extending police powers in this way.

Amendments 128B and 158 would introduce a new category of “authorised person” under Sections 135 and 136 of the Act respectively. These functions of the Mental Health Act can currently be carried out only by the police. The two amendments propose different lists of who could be considered an “authorised person” for the purposes of these sections. Under Section 135, the role of the police is to support mental health professionals to enter someone’s home, by force if necessary, with a warrant, where there are concerns about their mental health and then keep the person at home or take them to a place of safety. Extending the ability to health and social care professionals to enter someone’s home without their permission would be a major shift in their roles—the noble Baroness, Lady Watkins, alerted the Committee to that—and it would impact on relationships between patients and health and care staff.

On the amendments from the noble Baroness, Lady May, whose intention is to ensure better interagency response and remove the need for the presence of the police at mental health incidents in the absence of any risk, we feel that Section 135 already represents positive interagency working, with police supporting health professionals to gain access to a property when there is cause to suspect that a person suffering from a mental disorder is, for example, being ill-treated or neglected and when access to the property has been denied. Of course, if health professionals can gain access with the permission of the patient, there is no need to involve the police.

Section 136 allows the police to remove someone to, or keep them at, a place of safety, by force if necessary, if they appear to be suffering from a mental disorder and need immediate care or control. Again, extending this power to health and social care staff would represent a major shift in their relationship with patients and the public. While in some cases approved mental health practitioners already have these powers—they can, for example, normally enter properties with permission—for other professionals, such as midwives or paramedics, the amendment would be a much more significant change.

The noble Baroness, Lady May, cited a number of statistics and I appreciated those. We have explored the proposals from the NPCC. I noted the significant concerns articulated so well by the noble Baroness, Lady Watkins, but we have heard considerable concerns expressed also by health and care professionals and therefore we need to be minded in that respect. There are also concerns about the potential impact on staffing in an already stretched workforce, which has been discussed already in this Chamber. Any consideration of changes in these powers would need extensive engagement with other professional bodies, patients and the public, as well as an assessment of impact and costs.

All that said, we absolutely recognise that there is much more to do to support better handover to health services when the police are involved, particularly in A&E, as the noble Baroness, Lady Tyler, spoke about. This was something that the PLS committee identified, so we will continue to engage with police and health and social care partners around better management of patients in A&E and the reduction of the role of the police.

On the point made by the noble Baroness, Lady May, about the provision of services to people while being looked after by the police, we are committing £26 million in capital investment to open new mental health crisis centres, to which I referred in an earlier group, which will aim to provide accessible and responsive care for individuals in mental health crisis. The purpose extends beyond reducing A&E attendance. Evidence from systems with established crisis centres indicates that they can help streamline urgent mental health care pathways and reduce unnecessary conveyance to A&E by ambulance, health-based transport or the police.

Let me turn to the code of practice. It is clear that health professionals, police and others should have partnership arrangements to support people in mental health crisis and ensure they receive care from the most appropriate service as soon as possible. When the police are involved, I absolutely agree that they must be able to hand over to health professionals as quickly as possible. As I said, in looking at the revised code of practice, we would hope to make progress in this regard.

The noble Baroness, Lady Buscombe, asked for an update on Right Care, Right Person. I can say that almost all forces in England and Wales have rolled this out. Nationally, rollout, including concerns around implementation, continues to be reviewed and discussed at the RCRP oversight group. That forum brings together those with clinical, operational and policy expertise to review and discuss the concerns that have been reported in relation to implementation, to record any risks or delivery issues and to identify potential actions needed to address concerns, including at national level. I know that my colleagues at the Home Office are, obviously, very engaged on this. It is something that we also liaise with them about.

Finally, I turn to Amendment 49A in the name of the noble Baroness, Lady Barker. The amendment intends to allow non-medic approved clinicians, such as nurses, psychotherapists, social workers and occupational therapists, to be automatically approved to provide the medical recommendations needed under Section 12 to detain someone or receive them into guardianship under certain provisions of the Act. First, let me put on record my thanks for, and recognition of, the increasingly important role that non-medic approved clinicians play in the operation of the Mental Health Act. Psychologists, nurses, OTs and social workers bring a wealth of expertise and alternative professional perspectives that strengthen the role of approved clinicians as a whole. They will continue to play a vital role in the implementation of the reforms set out in the Mental Health Bill. However, it is important to recognise the distinction between the role of an approved clinician once a patient is detained and the purpose of the “medical recommendation” at the point of detention, as set out in Section 12, which is, as noble Lords will be aware, mainly about the medical recommendation required for initial detention. At this point, it is sometimes not known whether a patient has a mental health condition. There may be other medical reasons why a patient is presenting in a way that has triggered a Mental Health Act assessment.

A Section 12 doctor provides an experienced and expert medical recommendation as to whether there is a mental disorder that warrants detention, to inform the decision of the approved mental health professional. We believe that this should remain a judgment for someone with the appropriate skills and competency, such as a registered medical practitioner.

I noted in preparing for this group that neither the independent review nor the Joint Committee made any recommendations to change this part of the detention process. This amendment would fundamentally change the medical recommendation on the detention process without a strong enough rationale.

I turn to the point raised by the noble Baroness, Lady Buscombe, about digitalisation and the possible solutions. I was grateful to her for already having raised this in our previous engagement. As the noble Baroness referred to, we are keen to ensure, and will ensure, that the digital version of the advance choice document will be available at the point of need. We are currently working with NHS England to identify what investment is needed and how this may be possible. We can draw on the example led by the South London and Maudsley NHS Foundation Trust, King’s College London and Bipolar UK. Our aim is to ensure, through a digital format, that people can express their wishes and feelings using a range of means, in a way that best suits them. This is, of course, a very strong aspect of that. With that, I hope that the noble Baroness will feel able—

I thank the Minister for her characteristically full and attentive response. I understand why she is not too enamoured by my amendment, and I do not intend to push that much further. However, having listened to her response to the noble Baroness, Lady May, I cannot help but arrive at the conclusion that, while we are quite content, because we all agree, to see police officers being taken away, we are not going to change anybody else’s roles or responsibilities to plug what will be an inevitable gap. I return to something I have said today and previously: this will be the only mental health legislation for 20 years. If we let this go through, in the certain knowledge that we are creating a big gap which will not be filled by existing roles or the deployment of people within the NHS, we are being quite negligent. We are consigning a lot of people to finding themselves without appropriate support at moments of distress, and that goes for staff who happen to be around at the same time. The noble Baroness, Lady May, is a fan of Geoffrey Boycott. I hope that she goes in to bat again and does not give up. There is an enormous gap here and we have just made it worse.

I appreciate the contribution of the noble Baroness. None of us, including the Government, wishes to create a gap, either intentionally or unintentionally. I should have said in my remarks that the noble Earl, Lord Howe, asked whether I would meet the noble Baroness, Lady May, should she so wish. The answer is yes. I was glad to do so previously with the Secretary of State; it was extremely helpful. I assure the noble Baroness, Lady Barker, that there is no intention to create a gap, and we would be happy to elaborate further. She is absolutely right to say that we should be cautious and that it would not be good legislation to do that. The challenge is whether the amendments before us are the answer. I hope that this is a helpful comment.

19:15:00

I have listened very carefully to the debate on this set of amendments. Those in the name of the noble Baroness, Lady May, would create a specialism within the relevant professions which is not there at the moment, based on a change of law. The Minister’s response was focused on the skills of people now, based on their generic roles. My question is this: in responding to the noble Baroness, Lady May, did officials and the Minister look at the potential change that would happen to the skill set, and at the skills and professionals that would be specific for this purpose? In practice, if the law changed, that is exactly what would happen to those professions: a subset of skills would develop, which would allow the gap to which my noble friend alluded to be closed.

With your Lordships’ permission, I want to respond to what the noble Lord has just said. On the front line in this are the paramedics; they are the ones who will have to deal with this issue, most of the time. They need recognition for the additional work that they are already doing. The noble Baroness referred to the gap—the gap is being filled, but in a very inefficient and unrecognised way. We need to recognise that this is something that needs to be dealt with properly, with the staff involved being given the appropriate powers to deliver.

To add to that, the key thing about paramedics is that they do not have long-term therapeutic relationships with the people we are talking about. Therefore, an intervention is totally appropriate.

I too want to add, equally with great care, to this very interesting discussion. I am concerned about the police. I have not quite understood from the Minister her thoughts on a point that has been made twice now by the noble Lord, Lord Meston about everybody waiting for the police. Are the Government thinking of making it unnecessary for the police regularly to attend?

I thank noble Lords for their interventions. To the noble and learned Baroness, Lady Butler-Sloss—how can I put this?—I say that the police should be there only when they are needed because they are the police. It is true—the point was made very well in the course of the debate introduced by the noble Baroness, Lady May—that it often goes beyond that. That is why “right care, right person” is something that colleagues are working on with police forces, as well as looking at the whole connection with health services. It is well understood. I heard the comments of my noble friend, as well as those of the noble Baroness, Lady Watkins, following on from the noble Lord, Lord Scriven. When the noble Lord, Lord Scriven, was speaking, the words that came into my head were “chicken and egg”, about legislation and skills. We looked at skills, but—these are not quite the right words—not at the expense of addressing the question of whether the law is in the right place. They are connected, but I refer the noble Lord to the points made earlier, by me and the noble Baroness, Lady Watkins, about the response we have had from health and care professionals. It is about finding the right way. I take the point that there is a gap now. We do not want to make it worse, and we know that it is not acceptable.

My Lords, may I say how grateful I am to all those across the House who have supported my amendments. When the Minister first stood up and started to respond, I got quite excited and hopeful. I thought the points had landed, but then, as she carried on speaking, my hopes were dashed as I realised that, in a very elegant way, she was actually rejecting all the points that I had made in my amendments. The Minister emphasised the code of practice and dealing with the issue of the handover between police and medical professionals. The whole point of my amendments was to ensure fewer handovers between the police and medical professionals, because there would be fewer times when the police were called as the first responders to a mental health incident. The Minister kindly said she would meet with me, and I hope she might be willing for the noble Lord, Lord Davies, also to be part of that discussion. The noble Baroness, Lady Barker, referenced my admiration for Sir Geoffrey Boycott. One thing about Sir Geoffrey Boycott was that his centuries tended to come quite slowly. Maybe the response and government reaction to this will be a little slower than I had anticipated; but, on the basis that I anticipate that that reaction may come and the century may be scored, I beg leave to withdraw the amendment.

Amendment 37B withdrawn.

Amendments 37C to 41 not moved.

Amendment 42 had been withdrawn from the Marshalled List.

Amendments 42A to 42F not moved.

Clause 5 agreed.

Clause 6: Grounds for community treatment orders

Amendments 42G and 42H not moved.

Amendment 43

Moved by

43: Clause 6, page 12, line 33, at end insert “, including access to a prescribing psychiatrist local to their place of residence”

My Lords, Amendment 43 in my name is to a list of grounds under which community treatment orders will be allowed. I have to say that, judging by the Second Reading of the Bill, including my own contribution, community treatment orders have not been a great success. I think that is a general view but here they are, listed in the Bill, and it is incumbent upon us to make them as strong and comprehensive as possible so that they are fit for purpose, if they are to remain. I felt that there was an omission from the list of grounds in the Bill. I say to the Minister that I put my hand up immediately: I have had this this discussion with her outside the Chamber. This is something that I want to put into the Bill, but I am still not entirely sure that this is the right place for it. I hope she will not bat it out of—I do not know what to say in cricketing terms because I do not have my noble friend’s expertise in cricket. Anyway, I shall quickly move on. We know the problem: there is a shortage of psychiatrists. In some areas, people are well served but in others they are not. Today’s debate has focused on psychiatrists who have expertise in autism and learning disability. I am looking at a scenario where a person has autism or a learning disability, as well as a recognised mental health condition, and is discharged into the community on a community treatment order. Despite what I have said about my reservations about them in principle, because there is such a paucity of psychiatrists, particularly those who have expertise in autism and learning disability, once that person is being cared for on a community treatment order—or, for that matter, someone in the community who is not on a community treatment order but is medicated—where are the psychiatrists that they can turn to? To my certain knowledge, there are around the country some integrated care boards that feel they are serving the autism community well enough if they can identify psychologists with expertise. There is nothing wrong with that, as there are excellent psychologists around the country, but of course, psychologists cannot prescribe. So there is a real challenge for people in that situation who need ongoing medication—the dosage of which may need to be changed, for example—having local access to an appropriate psychiatrist. I am a bit nervous about the wording of the amendment—it is my wording, but I am still nervous about it—as it includes the word “local”. I assure the Minister that I am realistic enough to know that there is not going to be an appropriate psychiatrist just round the corner, but in many cases, as I am personally aware, there is not even anyone in the county. If someone has been subject to an in-patient stay in a mental health hospital, admitted in an emergency, that does not necessarily mean they are going to be in a local hospital; because of the shortage of beds, they may be quite far from home. So the community treatment order may not be exercised close to where someone has previously been an in-patient. We also have problems at the borders between Wales, England and Scotland. For mental health services, there are mutually agreed agreements about where patients can be seen, and particularly where hospitalisation can take place. However, if community treatment orders are to be maintained, on discharge they may well be a long way away from where they live. That is why I have added my wording at the end of the list of grounds for community treatment orders. We in Parliament make a great virtue of saying that decisions are made at local level. That is all well and good, but if the decision made at local level is, “We don’t need a psychiatrist within our geographic area who has that expertise”, that is not much help to the patient. I have shared with the Minister cases involving people who are not necessarily under a community treatment order but who have an ongoing need for medication and cannot access a psychiatrist with that expertise, and who end up having to travel to centres of population and paying very nice fees, thank you, privately because it is not available in any other way. That cannot be right, which is why I have added my wording to the list of grounds for CTOs. If the Minister does not think that that clause is the appropriate place for it, I will understand; but if so, I hope she will tell me where in Bill it should go, because I really believe it should be there. As a postscript that has nothing to do with community treatment orders, for people with mental health conditions who need medication, people with autism without mental health conditions—I am looking away from the noble Baroness, Lady Murphy, at this point—and people with autism who need ongoing medication for, for example, autism-related anxiety, personalised medicine is going to be a real advantage, enabling them to know exactly the right drug and the right dosage. It is out of reach on the NHS at the moment, but personalised medicine, using DNA testing to get the right dosage, is very good. I hope we are going to see it pretty soon, particularly in mental health. Let us start with mental health. I beg to move.

House resumed. Committee to begin again not before 8.30 pm.