Skip to main content

Mental Health Bill [HL]

Volume 689: debated on Monday 26 February 2007

25: After Clause 21, insert the following new Clause—

“Children and young people

After section 142 of the 1983 Act insert—

“142A Admission to age appropriate setting

In the case of an application for admission for assessment and treatment for a mental disorder, whether voluntary or not, in the case of any child or young person under the age of 18 years, a clinician with specialist training in child or adolescent mental health shall assess the needs of the child or young person and a PCT or equivalent health board shall provide for such services and accommodation as are sufficient for the particular needs of that child or young person.

142B Medical assessment by a CAMHS specialist prior to imposition of compulsion for a child or young person

In the case of a minor under the age of 18, who is admitted for assessment under section 2 or admitted for treatment under section 3, one recommendation as specified in these sections shall, except in an emergency where no child or adolescent mental health specialist is available, be made by a qualified child and adolescent registered medical practitioner.

142C Clinical supervisor

Wherever under any provision of this Act a responsible clinician is to be appointed if the patient is a minor under 18 that clinician shall, except in an emergency where no child and adolescent mental health specialist is available, be a child and adolescent mental health specialist.””

The noble Lord said: My Lords, as this is the first amendment I have moved at this stage of the Bill, I should like to say that I appreciate the efforts the Minister has made to respond to the many points which rained down during Committee. I think we can say that there are at least some rays of sunshine—I hope we will see them on this amendment and on others. The Minister knows, however, that I and other noble Lords who have put their name to the amendment attach much importance to it, which concerns children and young people exclusively.

The first part of the amendment deals with the requirement to treat children and young persons under the age of 18 in a way appropriate to their needs. The public might think that this is so self-evident that we should not have to debate it on the Floor of the House. However, we know that despite the very great improvements in mental health care and services in recent years, in practice children and young persons with mental health problems and disorders are not always treated in an age-appropriate setting. My noble friend Lord Patel of Bradford gave some shocking examples when he spoke in Committee, and the very recent report by the Children’s Commissioner, entitled Pushed into the Shadows, has some more.

In presenting this Bill, the Government have given Parliament the right opportunity to improve the present situation for children and young people. We know that many mental health problems come about in the teenage years and that the best assessment and care at this time and the confidence of the patient in his or her treatment can give longer-term benefits, and perhaps help to reduce the revolving-door phenomenon under which mental health patients go in and out of hospital, which it is one of the Bill’s objectives to reduce.

More specifically, the amendment requires first that for children and young persons under the age of 18, when there is an application for admission and treatment for a mental disorder, there should be an assessment by a medical practitioner with specialist training in child or adolescent mental health; and secondly that the health authority or equivalent health body,

“shall provide for such services and accommodation as are sufficient for the particular needs of that child or young person”.

We find this quite appropriate to the Bill, as did our Scottish colleagues when they included the same words in Section 23 of the Mental Health (Care and Treatment) (Scotland) Act 2003, thereby setting an excellent precedent.

We recognise that in proposing including the appropriate treatment test in the criteria for detention, the Government have recognised that there is a problem and sought to provide a partial remedy. To that extent, there is common ground between us. But the effect could be that if the primary care trust did not provide care in a CAMHS unit and an adult unit was deemed not safe, the child or young person could not be detained and would not get the place of safety which might be necessary. Nor does the Government’s approach deal with children or young people to be admitted on a voluntary basis. Our approach is more direct and, in our view, more reliably effective.

At an early stage, the Minister indicated that it is not appropriate to put services on the face of the Bill. We are frankly baffled by that argument. As a former civil servant, I feel tempted to say that it must have been invented by a civil servant. The Mental Health Act, as amended by this Bill, is littered with service provisions, which is a good thing. As Rosie Winterton, the Minister of State, made clear on 30 January in the all-party parliamentary group: “This Bill is about making sure that people get the care they need”. Good for Rosie. In any event, in this amendment we are not talking about a newly differentiated group of people, such as market gardeners, asylum seekers or circus artists, but proposing an amendment for children and young people. In almost every sphere of our society we differentiate services for children and young people—for example, children’s hospitals, school buses, young offender institutions, the Children Act and so on.

The two remaining parts of this amendment are complementary to the first. They deal with medical assessment by a children and adult mental health specialist, and clinical supervision by a similarly qualified specialist for children and young persons under the age of 18. The Minister will note that for practical reasons these requirements can be over-ridden in case of urgency or emergency.

Finally, despite the Government’s good intentions, which we recognise, neither the code nor the Government’s policy guidance has protected the children who have been admitted to adult wards in past years and we are not convinced that a reiteration in the code will make much difference, which is why we invite the Government to put this provision in the Bill. I beg to move.

My Lords, I cannot better the case put forward by the noble Lord, Lord Williamson, in favour of this amendment, but I should like to express my firm support for it and to add some emphasis to a number of the points that he has so ably made. I begin by saying how much I endorse his arguments in favour of an age-appropriate setting for children and young people under the age of 18. This seems a classic example of a win-win amendment. We are all aware of real horror stories involving children who are sent to adult wards for treatment, and who are then molested and traumatised by adult patients. The experiences endured by young people in such circumstances are often terrible.

However, it is not only those horror stories that this amendment is about. It is about that central, key issue which has surfaced and resurfaced throughout our debates on this Bill; namely, that fear of the mental health care system engendered by traumatic experiences of whatever nature carries with it the potential for wholesale disengagement from mental health services in the future. The moment we see that happening—it happens often—there is only one consequence. The child or young person will not wish to seek help from anyone—they are turned off. They will hide their symptoms and carry on in a state of acute mental distress until they have reached crisis point. The irony is that having reached that crisis point, they are more likely to be treated under compulsion—so the trauma repeats itself.

The acuity of need among some young people carried over into adulthood is a cause for grave concern. Recent research has shown that almost 78 per cent of adult service users receiving intensive services had received a diagnosis before the age of 18; 60 per cent had received such a diagnosis before the age of 15. Those figures underline the importance of making sure that children and young people with mental health problems receive the services that are appropriate to their needs and which make them want to trust and use those services in the future if they need to.

The Minister may well fall back on the standard response by saying that this is an amendment about service provision, but I hope he will see that it is not just about that. It is about doing the thing that Ministers have repeatedly said that they want this Bill to do; namely, to make sure that people get the care they need when compulsion has to be used. The Minister said in Committee that it was difficult to specify services to a particular group. I must say that I did not really follow that argument; when I think of all the Bills that we have debated in this House over the past few years relating to children and services to children, I wonder where that argument came from.

Nobody doubts the Government’s sincerity in wanting to see better mental health services for children and young people. We hear the right things being said, both in the code of practice and the children’s NSF, but we know from the royal college, the Children’s Commissioner and the noble Lord, Lord Patel, in Committee that neither policy guidance nor the code has delivered the desired results. Good practice is, regrettably, not the norm.

Research published in the BMJ shows that more than one-third of all young people admitted to hospital for a mental illness are admitted to a general psychiatric or paediatric ward. Something more needs to be done. We know that the implementation of standard 9 in the NSF is receiving what the Minister, Ivan Lewis, called unprecedented priority, and that resources are being put into that whole area with the aim of solving the problem over the next two years. That is what Mr Lewis has said—and, if it is so, there really should be no argument about giving statutory backing to the notion of an age-appropriate setting. For once, we are not faced by funding constraints, because the funding has already been allocated, so I hope that the Minister will be receptive and sympathetic to everything that the noble Lord, Lord Williamson, argued for.

My Lords, I begin my brief remarks with an acknowledgment that the Government’s injection of funds into the health service over the past seven years has enabled some very significant improvements in in-patient services for children and young people. In east London, where I am the chairman of a mental health trust, we opened last year a purpose-built and beautiful new unit for children and young people, with 15 in-patient beds and six day places. We are very proud of the service that we can now provide, but my staff tell me how incredibly lucky we are. They are appalled at how children are treated up and down the country in places where, sadly, boroughs and trusts do not have the facilities that we have.

The reality is that the number of general NHS CAMHS beds has increased by only 4 per cent between 1999 and 2006. The result is that many areas still admit children and young people to adult wards and rely on the private sector, where the young person may be many miles from home and the cost may be exorbitant. Until last year, we were in that position; we were placing children from the east end of London down in Sussex or Berkshire. Noble Lords can imagine how often parents could visit those children—and there was no chance of the children coming by day, which is very important for some categories of disorder, such as anorexia.

We know from the Children and Young Person’s Inpatient Evaluation Study of in-patient care for eight to 18 year-olds that in-patient care is effective for very severe levels of disorder. In some of these cases, we can prevent the situation getting out of control and becoming absolutely chronic. In the study, the children showed considerable recovery, which was clinically significant, and family relationships, which are so crucial to a child’s well-being, improved—and the improvement continued over a one-year follow-up period.

In supporting this amendment, I am mindful of the conclusion of the Department of Health’s Every Child Matters report that CAMHS,

“should expect to achieve by the mid-point of the NSF cycle the elimination of the use of adult wards for all but a few older adolescents who find themselves associating more readily with young adults”.

This amendment seeks only to ensure that sufficient priority is given to achieving the objectives set out in the Government’s own report.

The Minister for Care Services, Ivan Lewis, agrees with us. He said that,

“we should be seeking a situation where no child ends up in an adult ward environment”.

He went on to say that,

“that should be our … mission”.

It is our mission today.

One of the central tenets of medicine is that health services should not do harm. But the Children’s Commissioner, Professor Sir Al Aynsley-Green, said he feared that children could be more damaged than helped by the experience of being on an adult psychiatric ward. As someone who makes a point of regularly meeting patients and staff on adult wards, I share that view. The reality of adult in-patient wards today is that staff are managing in-patients with ever more serious and complex psychiatric disorders. Anyone who can be managed in the community is managed by one of the community teams, even if that involves daily visits—three or four visits a day—and hours of every day being spent in that person’s home. The result is that any in-patient is likely to be severely disturbed. You do not have the sort of balance that you had 10 years ago where you had a number of reasonably stable patients and others who were a bit more disturbed. Today, everybody in those wards is a severely disturbed person. Thus, it is ever more urgent to avoid children and young persons being placed in a highly volatile adult in-patient environment.

In Committee the Minister suggested that the Mental Health Act was concerned with the legal processes around mental health and that:

“It is much more difficult to move on from there to specifying services to be provided to a certain group”.—[Official Report, 15/1/07; col. 559.]

In fact, proposed new Sections 142B and 142C in the amendment refer exclusively to detained young people. The Bill is very clear about who will be involved in the assessment of adults under the Act. It seems entirely in keeping with the spirit of the Bill that it should specify that appropriately qualified clinicians must be involved in the assessment of young people. Proposed new Section 142A refers to voluntary patients under the age of 18. In view of the seriousness of the consequences of inappropriate placement of these young persons, it seems reasonable to extend the scope of the clause as proposed. I hope that the Minister will give the amendment sympathetic consideration.

My Lords, I support the amendment. Noble Lords who spoke made the case clearly. It seems to me absolutely incredible and shocking that vulnerable children are put in the very highly disturbed atmosphere of an adult ward. I hope that the Minister can encourage us to think that that will not happen in the future.

My Lords, I wish to make it quite clear that these Benches support the amendment. Such was the enthusiasm of your Lordships for the amendment that there was no room to add my name to it, but these Benches enthusiastically support it.

The British Government are a signatory to the UN Convention on the Rights of the Child, which states that,

“every child deprived of liberty shall be separated from adults unless it is considered in the child’s best interest not to do so”.

I know that the Government are doing their very best to implement that responsibility. In fact, great progress has been made within the criminal justice system to do that. We also know that it is the Government’s intention that children should be in age-appropriate settings when they have mental health treatment.

Like the noble Earl, Lord Howe, I am relieved to be able to support the amendment without having to make any additional spending commitment. It is clear from Ivan Lewis’s statements that the Government have earmarked the necessary resources to go that step further so that no child will need to go into an adult ward in future.

If we needed any proof that this amendment was necessary, we have only to read the report of the Children’s Commissioner, to which reference has been made. The Minister says that the amendment seeks to enshrine good practice in the Bill; the Children’s Commissioner’s report makes it clear that that is necessary.

My Lords, I have added my name to the amendment. I do not want to speak further about the humanity behind it because I think that almost everyone in the House is agreed on that and it was well exposed today. I want to talk about the practicalities.

I know that the Government are concerned about amendments that dictate how services should be provided and about the possible extra cost that might suddenly be imposed. In reality, however, we have imposed special legislation for, for example, high-security patients, maternity services and cancer services, so there is absolutely no reason why we should not dictate what services are necessary.

In terms of practicality, what generally happens is that a child is admitted in an emergency; that is when the situation arises whereby they go into a completely unsuitable adult ward. In practice, all that has to happen is that the primary care trust agrees with the local mental health service that they will, for the moment, until the local facilities have been built, commission a certain number of emergency service beds. Indeed, that happens in most places where they commission emergency service beds from a range of young people’s facilities to ensure that in an emergency someone can make the decision about admission, and the money is there to fund it without question.

The money is being spent already because the person is admitted, so you already have the charge against an admission. Although the cost of a child’s admission to a specialist unit is slightly higher, the cost overall is broadly similar. All the amendment would do is signal to mental health services and primary care trusts that they have to make the arrangements. It does not signify that they should make a different sort of service.

This does not happen at the moment because of a handful of services that simply do not comply; it is evident from the Mental Health Act Commission reports that this is not a generalised problem but a problem with a very few authorities. We are not asking for anything complicated here. I support the amendment.

My Lords, I have listened to what has been said on the amendment, and I took part in the debate on Friday on palliative care, where the argument was that if you got rid of the postcode lottery it would put palliative care above other services. This amendment clearly does not do that for these services; there is every reason to put this in the Bill. Having heard some of the stories today, and having seen some of them in the paper, I believe that this is something that the Minister must surely agree to.

My Lords, I have tabled amendments concerning one part of the population that needs special treatment, which is those in custody. No group in custody is more in need of improvements to current mental health care than people of juvenile or young offender status—that is, those between the ages of 15 and 21. The services that they get are frankly awful, because there are simply not enough adolescent psychiatrists or trained adolescent nurses available to give the treatment that they need. The assessments are not there. All the things that are set out in the amendment, if adopted, should be adopted on behalf of all those young offenders who get into the hands of the criminal justice system. I strongly support the amendment, because it sets out a very clear blueprint for what the authorities should provide, so I hope that it will be accepted.

My Lords, I add my strong support to the amendment, which is very important. It is to do with focusing the response to young people with particular needs. Lying in the background is the problem that mental health services so often are the poor relation in local health authorities. Therefore, young people can be disadvantaged twice. One hopes that good practice in the field will be encouraged, but statutory provision, which would give strength to that, is practically needed, as we have heard.

My Lords, this has been a short but highly interesting debate. I sense that the House wishes to come to a view on this subject as quickly as possible.

I thank the noble Lord, Lord Williamson, for his very kind remarks. He has raised some serious matters about the way in which children and young people are treated by our mental health services under the legislation. He identified, as did the noble Earl, Lord Howe, some of the real challenges in ensuring that appropriate services are provided to these vulnerable young people. I also very much take the point that the right reverend Prelate made; he raised the concern that, traditionally and historically, mental health services have not received their due. As he put it, statutory provision is a way of ensuring that that happens. Noble Lords will be weary of me expressing concerns about, in essence, putting statutory requirements in the Bill to provide services, but that is a genuine issue that has to be faced up to.

The noble Baroness, Lady Howe, referred to one of the best debates that I have taken part in; it took place in your Lordships’ House on Friday. I very foolishly tempted the noble Lord, Lord Carlile, to engage with me on the issue of palliative care services. On Friday, all of us—apart from me, once again—were arguing that palliative care is so important. I could have taken the words that the noble Lord, Lord Ramsbotham, used about mental health services in Committee and simply inserted the words “palliative care”.

There are six areas for short debate on today’s selection list, all of which will be very interesting if we get to them. However, in all of them, noble Lords will argue that those are the areas that deserve priority. There is a genuine issue about how to provide these services, which are so important. We are dealing with such vulnerable people and there have clearly been major defects in the provision of services in the past; I refer to young people being looked after on adult psychiatric wards although they are vulnerable in the way that the noble Earl, Lord Howe, described. Those are major challenges but they are not solved simply by waving the magic wand of legislation that says, “That will happen no more”. That is the issue that separates us.

We have discussed Scotland on a number of occasions and all of us are interested in, and will be interested in observing in the years ahead, the different approaches and the lessons to be learnt from each system. Section 23 of the Scottish mental health Act requires a child to be placed in age-appropriate accommodation. However, that has not led to the ending of children being placed on adult psychiatric wards in Scotland. My understanding is that the Mental Welfare Commission for Scotland reported in the past quarter that admissions of children to non-specialist wards including adult wards had risen, not fallen. That is not a criticism that I make of Scotland or the Scottish approach. All I suggest is that noble Lords should bear in mind that simply passing legislation that says, “It will not happen”, does not mean that the service automatically follows.

My Lords, will the Minister admit that all that we as parliamentarians have the power to do is, alas, to pass legislation? It is up to the Government to make the thing work.

My Lords, I say very respectfully to the noble Lord that that really is a get-out.

Noble Lords are using our debates—I think that this is my seventh day of debate, although other noble Lords had a further debate at Second Reading—to identify issues and problems that have been in mental health provision for many years. They are clearly seeking to use this occasion to press the Government as much as possible to improve the provision of mental health services. I well understand that that is what this is about. Indeed, if I were back on the Back Benches, I have no doubt that I would be joining in those debates, as noble Lords know that I have a long-standing interest in the provision of better mental health services. However, any Minister standing here still needs to say that, although it would be very easy if parliamentarians could simply pass Bills and amendments saying, “This must be the priority”, that cannot be done, because overall discretion has to be given to the Secretary of State to provide services. The Secretary of State must then do his or her best to ensure that those services are provided.

My Lords, I am puzzled as to why the noble Lord keeps using the word “priority”. Those of us who support the amendment, and indeed other comparable amendments, are trying to set standards, not priorities over other things. Surely the word “priority” is rather misleading; if anything, it is a parity, not a priority.

My Lords, I do not agree with that. It seems to me that the code of practice, to which there is statutory reference, is the ideal place to embody standards. If in NHS legislation a Secretary of State is given a general duty to provide services but you detail in specific legislation a statutory requirement in relation to a particular aspect of the service, surely a provider of services is then left with certain statutory provisions that say, “In a certain area, you must provide services”, whereas the entire NHS services are governed by a more general duty. In that sense, by specifying in one area that a particular service must be provided, you are prioritising that service.

I think that noble Lords probably have the gist of my argument and I see that I have been as convincing as ever. I would only say that, as I am glad to report and as other noble Lords have acknowledged, there has been a tremendous advance in providing services for children and young people in the mental health field. We are seeing more in-patient beds being commissioned and more resources being spent. Indeed, the Royal College of Psychiatrists’ research unit provides some evidence of that. Noble Lords have referred to the comments of my honourable friend Mr Ivan Lewis; we are committed to doing everything that we can to improve those services.

My Lords, does the Minister regard a 4 per cent increase between 1999 and 2006 in general CAMHS beds as sufficient, bearing in mind the enormous importance, which I think he accepts, of providing the right kind of services to very young people who become mentally ill?

My Lords, I think that I said earlier that major challenges remain to be faced. I would never claim that the provision of those extra beds is sufficient, but it is an indicator of the improvements that are being made, alongside other improvements in relation to CAMHS and mental health services generally. The Government’s view is that we signalled our intent to improve services. We believe that the code of practice is the right way to indicate to the health service how those services should be provided and, as I have indicated, we are very wary of accepting the kind of amendment and approach put forward by the noble Lord, Lord Williamson, this afternoon.

Yes, my Lords, and that is made absolutely clear in the code of practice. Of course, there is no question about providing as good a service as we can for children and young people, but I do not think that that alters the arguments in relation to the amendment.

My Lords, I am grateful to the Minister for his reply. I am sure that his motivation is very similar to our own. We are trying to improve care and provide appropriate care for children and young people.

I noted that the Minister pressed two points. He said that putting the amendment in the Bill is no guarantee that it will happen. We all know that one cannot just put something into a Bill and assume that it will happen the next day—most of our legislation probably falls into that category. However, we still believe that it is right to put it into the Bill.

Before the Minister rose, I tried to answer the point about the specific position of children. Throughout much of our society and in legislation, we treat children and young people quite separately. I do not believe that this is comparable with various other points that might be raised about setting services. I noted that the Minister said that if he returned to the Back Benches he would perhaps join in these debates.

My Lords, to ensure that I do not return to the Back Benches very soon, I need to clarify that. Of course, I would not support the amendment, but I was responding to a general comment from the noble Lord, Lord Northbourne, that of course the passage of a Bill is an ideal way in which to press the Government to improve services in the particular area that is under discussion.

My Lords, I thank the Minister for that clarification. I do not want him on the Back Benches; I want him on the Front Bench, as there is plenty more business to come on which he can give us a helpful hand. In the mean time, I consider that this amendment ought to be in the Bill. I beg leave to test the opinion of the House.