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Mental Health Act: CQC Report

Volume 636: debated on Tuesday 27 February 2018

(Urgent Question): Thank you very much for granting this urgent question, Mr Speaker. This morning, the Care Quality Commission published—

Order. I am immensely grateful to the hon. Lady, but she needs to say, “To ask the Minister for a statement, etc.” She will get her full go—her full bite at the cherry—when the Minister has delivered the initial statement. That is the way it works.

To ask the Secretary of State for Health and Social Care to make a statement on the Care Quality Commission’s report, “Monitoring the Mental Health Act in 2016/17”.

The Government welcome the CQC’s latest annual report, which it produces as part of its statutory duty to monitor how mental health providers exercise powers and discharge their duties when people are detained under the Mental Health Act 1983. We are committed to ensuring that the Act works better for patients and their families, and this is why we have commissioned an independent review led by Professor Sir Simon Wessely, which will make recommendations in autumn. We are also investing more in mental health than ever before, spending an estimated record £11.6bn this year.

We have seen that the number of detentions under the Act has been rising year on year: it rose by 2% last year and by 9% the year before that. We also know that black people are disproportionately affected. These were both driving reasons for the Prime Minister’s decision to call for a review of how the entire Act is operating. The Government have already acted when they saw that the Act was not working properly. Last year, we legislated to make it illegal to use police cells as places of safety for children under the Act, and to ensure that police officers consult health support staff before using their detention powers.

Sir Simon, his vice-chairs and the independent review’s team are consulting actively and widely with service users and professionals, and today are taking part in a major stakeholder event in Newcastle. Indeed, I welcome the fact that the CQC takes care in its report to state: “We have confidence that the independent review’s solutions-focused approach to identifying priorities, based on the feedback and experiences of people across the country, will offer a review of the MHA that has the confidence of patients and professionals.” The CQC is, of course, directly involved in that review.

The CQC’s report found examples of good practice, but we recognise that more needs to be done to ensure that people’s voices are heard and their rights respected. Where possible, we expect all patients to be involved in their care planning and that providers should consider how best to do this in the light of the CQC’s recommendations. In the spring, the review will provide an interim report identifying priorities for its work. It will then develop a final report containing detailed recommendations on its priorities. This final report should be delivered by autumn 2018.

There are problems with the Act, and we will address them, but we should remember that today no one gets sent to an asylum only to disappear within its walls. There are regular reviews, clear rights of appeal and checks to ensure that people are lawfully detained only to get the treatment they need. Our society is changing how it thinks about mental illness, however, and we want to ensure that people have as much liberty and autonomy as possible.

This scathing report finds that too many patients subject to the Mental Health Act continue to experience care that does not fully protect their rights or ensure their wellbeing. Some Members might have seen the harrowing episode of “Dispatches” last week, which showed scenes of a patient experiencing violent restraint at the Priory Group’s Dene Hospital. Today’s CQC report indicates that these experiences are not isolated. It shows no improvement in key areas of concern raised by the commission in previous years. It is totally unacceptable. In fact, some of the indicators are getting worse. Why is there still no evidence of patient involvement in 32% of care plans—up from 29% last year; of patients’ views being recorded in 31% of care plans—up from 26% last year; and of consideration of the least-restrictive care options in 17% of cases—up from 10% last year? This last, in particular, is a matter of serious concern. We know that the period following discharge from in-patient care is when most suicides happen. Why, then, in 24% of care plans was there no evidence that plans were made for discharging patients back home?

The report exposes the pressure on high secure hospital placements for women. One patient was in long-term segregation for over a year while waiting to access a bed. The Minister, to whom I listened closely, referred to the review by Sir Simon Wessely, but his review and report cannot provide answers to this patient or many hundreds more across the country today. Despite repeated Government promises of parity of esteem, we have seen yet another year of inaction. Does she accept that, in 2018 here in England, what is outlined in today’s CQC report is completely unacceptable, and will she tell us exactly what she is going to do this week to ensure that no patient in our country in a mental health unit is deprived unnecessarily of their human rights?

It is worth reminding the House why we introduced the CQC—to provide for transparent inquiry into the performance of our health services and so ensure they remain the best in the world. It is for precisely this reason—to make sure we do better—that we invite the CQC to do so so honestly and take any criticism arising from the transparent scrutiny that characterises this and all its reports. We recognise that we can always do better. The duty of candour in the NHS under this Government means that we will step up to the plate and respond to these challenges.

The hon. Lady describes the report as “scathing”. In fact, it highlights a positive direction of travel on access to advocates and promoting good physical health, and an improved direction of travel on care after discharge, so I do not accept the tenor with which she characterised the report. I would go further and quote the deputy chief executive of the CQC, who also highlighted the parallel review by Sir Simon Wessely. He says: “We have confidence that the independent review’s solutions-focused approach to identifying priorities, based on the feedback and experiences of people across the country, will offer a review of the MHA that has the confidence of patients and professionals.” The report also highlights that Sir Simon Wessely is already undertaking and identifying actions that can be taken outside new legislation, and the CQC is very much part of delivering that.

Far from being complacent, we recognise that we have a long way to go, which is one reason the Prime Minister has put mental health firmly at the top of our health agenda. The report identifies a positive direction of travel, but we will continue to turbo-charge it and deliver sustained improvements in mental health services.

One of the things that we are doing in prioritising mental health is dealing with exactly that issue. We are having discussions with every part of the health community. We recognise that all the professional organisations have a role in spreading best practice, but we need to do that as well, and the CQC report—and the fact that we are undertaking these reviews so transparently—will help us to do it.

Today’s report lays bare the problems that are at the heart of the Government’s short-sighted and incoherent approach to dealing with mental health issues. The CQC has found the system to be “under considerable pressure”, with no improvement in the areas of concern raised in previous reports.

Rather than taking a preventive approach to mental health treatment, the Government have made real-terms funding cuts which mean that more people are at risk of being detained and fewer detentions are being prevented. Crucially, those cuts are causing less restrictive alternatives for the community to be removed at the same time as the reductions in the number of beds for admissions. As the report tells us, the number of detentions under the Mental Health Act 1983 has risen by 36% since 2010, and between 2015 and 2016 it rose by more than 5,000. Will the Minister note that between 2000 and 2009 rates of detention fell, largely owing to investment in community services by the last Labour Government?

Recent research by the Royal College of Psychiatrists showed that mental health services have less money to spend on patient care in real terms than they did in 2012, and more than a quarter of clinical commissioning groups underspent their mental health budgets last year. The Government make many claims about the funds that they have pledged to mental health services—as the Minister has today—but it is clear that the money is not reaching the frontline. The CQC thinks that reform of mental health legislation on its own will not reduce the rate of detention, and reductions in mental health beds and community services are clearly contributing to the rise in the number of detentions. Is it not time to increase funding for mental health, and to ring-fence mental health budgets?

I repeat that we have increased mental health spending by £11.6 billion. The hon. Lady suggested that a quarter of CCGs are spending less than their allocations on mental health, but that is not the figure that I have. We believe that 85% of CCGs have increased their mental health expenditure in excess of their allocations, which does not chime with what she said about community services. It may give her some reassurance to know that from next year, NHS England will ensure that the mental health investment standard forms part of its planning guidance. [Interruption.] The hon. Lady says “Next year”, but, as I have said, 85% of CCGs are already meeting the standard, and those that are not are experiencing intervention from NHS England. We are satisfied that the 85%—and it will be 100% next year—are investing more in mental health services beyond their allocations.

I agree with the hon. Lady, and indeed with the CQC report, that the review of the Mental Health Act is not the entire answer. That is the reason for the CQC’s annual inspections, and we will act on its recommendations, but central to the work that Sir Simon Wessely is leading is identifying non-legislative action that we can take in order to make the system work better, and we are involved in many cross-Government initiatives that will enable us to do exactly that.

The report also concludes that the number of mental health wards without ready access to GPs has fallen from 25% in 2013-14 to just 7% now. Is that not welcome news, and another step in the right direction?

I thank my hon. Friend for that comment. He has highlighted both the reason why we tasked the CQC with conducting annual inspections and an instance in which, having been given a conclusion and a set of recommendations, we have delivered, and we will do the same in respect of this report.

The report makes clear the need for a major shift in focus that will place patients at the centre of their care. What is required is a human rights approach in which the least restrictive option is adhered to. Detention must be the last resort.

A key issue is that patients feel invisible in the present system. Will the Minister go to the frontline? Will she visit the hospitals, speak to the staff about resourcing, and speak to the patients and the carers who are in, and have been through, the system? Will she hold the focus groups that are so badly needed with patients and carers to ensure that the system is overhauled and their voices are heard?

The ethos that the hon. Lady has outlined is very much the one that is being proposed by Sir Simon Wessely, which is why he is organising round tables, but I assure her that I am visiting services at the frontline as well. At the core of the point that she has made is the issue of a rights-centred approach for mental health patients, and that too is at the centre of Sir Simon’s inquiry. Patients need to be empowered to ensure that they receive the right treatment. Central to that is the whole issue of consent, which is something that very much concerns me, and not just in the context of mental health. We may be able to take the lessons from Sir Simon Wessely’s review and apply them elsewhere in the NHS.

Does the Minister agree that a better laydown of mental health services, involving crisis houses and step-down facilities, might end the need for people to be admitted to acute mental health facilities in the first place, or else support them immediately after their discharge? Will she join me in encouraging the Somerset CCG to ensure that such facilities are available in that county as well?

My hon. Friend reached the nub of the issue in that final point. Commissioning is a matter for local commissioning groups. However, through the CQC report, the work that we are doing through the mental health investment standard and the scrutiny applied by NHS England, we are trying to ensure that there is a consistent application of good-quality services around the country. We find some centres of excellence and some areas in which the service is less patchy, but when it is less good it obviously leads to worse outcomes. We are determined to do our best to promote the best possible services throughout the country.

I welcome the Government’s outlawing of the use of police cells for those experiencing a mental health crisis, and I do not question the Minister’s commitment to improving the service, but the system is fragmented. There have been local authority cuts, including cuts in community services. The Health and Social Care Act 2012 leaves local commissioners to decide where the money goes, which has led to a confusing local picture and fragmentation. Do we not need to give people clear pathways out of hospital, and to ensure not only that the money goes to the right places, but that individuals know their rights and that local agencies know their responsibilities?

The hon. Gentleman’s point about people knowing their rights and providers and commissioners knowing their responsibilities is crucial to the whole issue, and I think it probably underlies the lack of parity of esteem hitherto. When it comes to the role of central Government, we want to continue to rely on local provision and local commissioning, but we also need to be clear about the standards of performance that people should be able to expect. We are being more transparent about where services are being delivered well and where they are being delivered less well, but I think the work that Sir Simon Wessely is doing will shine a light on exactly that, and will enable us to engage in a much more meaningful debate about what is appropriate.

Does the Minister agree that involving more patients in determining their own care packages and giving them more control over their own treatment is part of the treatment itself?

I totally agree. Feeling empowered and in control of one’s own care is quite a big part of the journey towards getting better. We are very concerned that we are still finding cases in which people are being detained under the Mental Health Act without being properly apprised of their rights under the Act, and without the support of advocates to represent them. Dealing with that is very much a priority as we drive improvement forward.

More than half of women with mental health problems have experienced violence or abuse, so may I ask the Minister what reforms will be made to the support available to women with mental health difficulties, particularly to reflect women’s experience of abuse in coercive or controlling relationships?

The hon. Lady raises an issue that is close to my heart. In my opening statement I highlighted the discrimination faced by black people in detention, but I could just as easily highlight the discrimination faced by women. As she says, if they become victims of domestic abuse or coercive relationships, they often face mental health challenges as a result, and they are more likely to be detained in those circumstances. I co-chair the women’s mental health taskforce with Katharine Sacks-Jones from Agenda, and towards the end of the year we are looking to bring forward concrete actions to tackle exactly this kind of discrimination and make mental health services more responsive for women.

As a doctor, I know how carefully doctors and other health professionals consider individuals before resorting to detention under the Mental Health Act. Does the increase in detentions under the Act reflect a general increase in mental health problems in the population, or can it be better explained by a greater proportion of people becoming so unwell that they need to be detained in order to support their care? What research is the Minister doing to determine which is the better explanation, and to ensure that we identify those people who are going to become severely ill in time to treat them?

Clearly, if we can determine the causes of the increase in mental health detention, that will become part of the toolkit that we use to tackle the issue. This is one of the things that we are asking Sir Simon Wessely to look at. There are anecdotal examples of why this might be happening, but the fact that we are seeing higher rates of detention among the black community and among women raises some interesting questions that will bear further examination. I recognise my hon. Friend’s point completely. Good medical practitioners will use detention under the Mental Health Act only as a last resort, and we must ensure that that good practice is spread as far as possible.

An acute mental health facility in my constituency has been forced to close because refurbishment would be too expensive, and patients are forced to travel a long way outside Bath. Is not a local facility much better suited to treating mental health problems than a facility that is many miles away, particularly because carers are a long way away as well?

Generally, I would say that local facilities were better, but there is also a tension between a local facility and a good facility. It is better that patients should get the best possible support rather than the closest possible support to them. That is a balancing act, and it is something that needs to be determined by local commissioners.

It is absolutely essential that every one of us should challenge the system to give more, but could we also talk up progress where it has been made? The Sussex partnership has had a difficult past, but it has gone from being rated as requiring improvement to being rated as good, and one of its categories has been rated as outstanding. Can we praise the staff who are doing things well?

We absolutely should do that. I often think that when we are challenging each other in this place about things that are poor, we end up talking our services down, but it remains the case that the NHS is the best health service in the world, and we should always celebrate that fact. Also, the fact that we are putting mental health services under such scrutiny is in itself driving an improvement in performance, because, as we all know, sunlight is the best disinfectant.

Further to that response, the CQC says that it has seen limited or no improvement in the key concerns that it has raised in previous years. The problems are long-standing and they have been raised by the quality regulator in previous reports to Parliament. Does the Minister not understand, when she tries to tell us that sunlight is the best disinfectant, that all we are seeing in our mental health services right now is clouds?

I would say to the hon. Lady that this report represents sunlight, not clouds. It is very transparent, and these are exactly the things that I will be holding myself and NHS England to deliver to address these points.

It is very worrying to hear the CQC’s judgment that there has been limited or no improvement, especially relating to the failure to involve patients in planning their care. The Government’s review of the Mental Health Act is therefore timely, and it rightly considers evidence from people who have experienced being sectioned. The report mentions significant variation in performance. Will my hon. Friend be looking into the performance of specific organisations? Can we have more transparency about the failures, down to specific organisation level? What steps are being taken to intervene earlier and to care for people better in order to avert crises and reduce the need for sectioning in the first place?

My hon. Friend will be aware that, in addition to this annual review of how the Act operates, the CQC is also involved in inspections at individual provider level. Those institutions that are not performing to the standards that we expect are under close scrutiny by the CQC. In fact, I have had exchanges on the Floor of the House about some of them. I repeat my point about the spirit in which we embrace the challenges offered in the report. We have asked the CQC to undertake this annual report precisely so that we can ensure that the Mental Health Act is operating properly, and I actually welcome its frankness. I do not run away from the criticisms in the report, because it highlights exactly where we need to take action.

If everything in the garden is lovely for mentally ill people, why am I constantly told by people in my constituency that another Government Department—namely, the Department for Work and Pensions—is getting loads of people who are mentally ill to be reassessed, having been out of work for several years in some cases? If the Government want to help mentally ill people, somebody should tell the DWP to stop sending these mentally sick people for reassessment.

The first thing I would say to the hon. Gentleman is that I am not pretending that everything is rosy. One of the reasons we are making this such a priority is precisely because it is not, and we are determined to deliver improvement. He mentions the DWP, but I do not think that we should write people with mental illness off and say that they can never work again. It is in that spirit that we are working with the DWP to look at where we can help people, through person-centred interventions, to get back into work if they are able to do so. That is exactly what we are doing, and I hope that it will become very successful.

Obviously, the CQC report will help to inform a lot of ongoing Government work. With that in mind, will the Minister assure the House that Sir Simon Wessely’s review will look at the concerns of people from ethnic minority communities, who have particular issues with detention at the moment?

I can give my hon. Friend that assurance. The increased prevalence of people with a black background being detained is very much part of Sir Simon’s review.

Is the Minister also aware of the CQC report out today that rates as inadequate the child and adolescent mental health services in the Birmingham Women’s and Children’s NHS Foundation Trust? That is partly because of its vacancy rate of 27%, which the report says has

“impacted directly upon patient care resulting in poor patient handovers, cancellation of appointments, increasing waiting lists, patients waiting allocation of care coordinators, inconsistent care and low staff morale.”

Does not this indicate that, contrary to what she says, mental health services are not getting the resources they need, either in Birmingham or anywhere else?

I was not aware of that report, but the hon. Gentleman highlights the positive influence of CQC inspection. He has highlighted a provider for which things are not going so well, and that will enable an intervention to be made through the CQC to improve performance. In the meantime, the local commissioners in Birmingham can buy services from other providers.

My hon. Friend the Minister is right to highlight some of the concerning figures in this report, but there are some encouraging ones too, and does she agree that those who get a mental health problem in the United Kingdom today have a higher chance of being diagnosed, treated and making a recovery than ever before in our history, and that this is largely due to the brilliant staff up and down this country in tackling this fight?

I completely agree with my hon. Friend: they are better than they ever have been, but that does not mean we cannot do better, and we must strive to do better.

The mind and the brain are intimately associated, and I heard a horrible story this morning of a man who, after having been in and out of prison and in the criminal justice system and in and out of mental health institutions throughout his life, only really discovered at the age of 44 that many of his problems had originated from a traumatic brain injury at the age of 17. If he had been properly treated then, and had the rehabilitation that is unfortunately not available to so many people today, he would not have been through all of this round of problems. So will the Minister make sure that we get proper rehabilitation services for everybody who has a traumatic brain injury?

The hon. Gentleman gives a very powerful example, which highlights better than any other we have heard today the challenge we face. Not only was that person failed at the time of having his brain injury, but it was not subsequently picked up as he went through the criminal justice system, and I often say that we can deal with one weak link in a chain of events, but when we have a succession of them, things go horribly wrong. It is very much top of my list to make sure we have better integration of services between health and the criminal justice system, to pick up precisely those situations.

The Minister rightly said that police cells are inappropriate places to detain people with mental health breakdown, but she and the Government must address the fact that the police have a duty of care to people in mental health crisis until they can deliver them to qualified mental health professionals. The right facilities are simply not available everywhere, and we must make sure that they are, both for the police and, more importantly, for people in the middle of a health crisis.

The hon. Gentleman is absolutely right. We have seen impressive and rapid rates of decline in the detention of patients in police cells, and I congratulate police forces and police and crime commissioners for helping to achieve that, but he is right that we need to make sure that, when people are taken to places of safety, suitable facilities are available for them.

Yesterday some of us were present when Esther Rantzen told us that calls to Childline from children with suicidal feelings had risen in 10 years from virtually none to over 22,000 last year, and the CQC report yesterday found that young patients are not receiving the mental health care they need. So can the Minister explain why only 7% of the overall mental health budget is spent on children, when children make up 20% of the population and 50% of enduring mental health conditions materialise by the age of 14?

The hon. Lady is right to highlight that point, and that is exactly why we have brought forward the children and young persons Green Paper, recognising that the earlier we intervene, the more likely we are to delay and prevent any long-term mental health issues. We are working with the Department for Education, and we are going to be rolling out 8,000 mental health support staff to work in schools to identify precisely that early intervention. The point the hon. Lady makes about Childline raises more questions about why the number of such calls have increased, and we need to do more to understand that. We know some of the social causes that lead to poor mental health, such as domestic violence and other kinds of trauma; they have been with us for a long time. We also need to look at whether there are other environmental factors contributing to that.

I say very plainly to the Minister that nobody on this side of the House is criticising the staff in the mental health services; we very much support them, but we need more of them and they need to be better resourced. Can she explain why we in West Yorkshire are one of only six authorities who have had year-on-year cuts for five years? We have now lost £20.4 million from the service. May I add that many people on the autism spectrum also find that they are in need of mental health services and they feel these cuts particularly?

As I have said, we have increased the amount of funding for mental health. That is separate, of course, to the commissioning decisions at local level by local authorities, who also have a role to play in this, as the hon. Gentleman knows. I am very conscious of the needs of people on the autism spectrum. We must give that support, and the things we are doing in terms of improving provision in schools will help identify people who are struggling with that. Planning for the future is great, but we are where we are now, and I join the hon. Gentleman in wholeheartedly congratulating staff up and down the country on their efforts in delivering a good service.

This CQC report shows that the bad old days of poor mental health care are creeping back: insufficient staff, a doubling of restriction, and a third of patients not involved in their care plan. Why do the Government continue to fail people with mental health conditions, and when do they expect all mental health services to be made safe—the most basic of requirements?

I disagree profoundly with the hon. Gentleman. This report shows that patients have increased access to advocates, that more attention is paid to the physical health of people with mental health treatment, and that there is better planning for aftercare and discharge, but we are being honest: we still need to do better, and I expect Members to hold me to the findings highlighted in the report.