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Mental Health In-patient Services: Improving Safety

Volume 831: debated on Monday 3 July 2023


The following Statement was made in the House of Commons on Wednesday 28 June.

“With permission, Mr Speaker, I would like to make a statement on improving safety in mental health in-patient services across England. Before doing so, I want to thank all the right honourable and honourable Members from across the country who have campaigned tirelessly on behalf of their constituents to improve mental health care. Too many people have experienced care in mental health in-patient settings that has been well below the high standard that we all deserve when we are at our most vulnerable. I would also like to put on record my sincere condolences to the families and friends of those who have lost their lives.

First, I will update the House on the independent inquiry into mental health in-patient care across NHS trusts in Essex between 2000 and 2020. I thank my right honourable friend the Member for Chelmsford (Vicky Ford) for tabling a Westminster Hall debate on the Essex mental health inquiry earlier this year. She and colleagues, including our honourable friend the Member for Rochford and Southend East (Sir James Duddridge) and our right honourable friends the Members for Witham (Priti Patel) and for Maldon (Sir John Whittingdale), all spoke passionately about the need to get justice for patients and their families. I know that my honourable friend the Member for South Suffolk (James Cartlidge) also tabled an adjournment debate on mental health in-patient care in Essex before the independent inquiry was launched in 2021.

I also pay tribute to my right honourable friend the Member for Saffron Walden (Kemi Badenoch) and my honourable friends the Members for Clacton (Giles Watling), for Brentwood and Ongar (Alex Burghart), for Castle Point (Rebecca Harris), and for Southend West (Anna Firth) for their determined campaigning on behalf of their constituents. Of course, we should all remember the important contribution of the former Member for Southend West, and a great friend to many across this house, the late Sir David Amess. He tabled a Westminster Hall debate on mental health services in Essex back in 2014, and he was a passionate campaigner for improving mental health care. I know he is very much in our thoughts.

In 2021 we launched the independent inquiry to investigate the deaths of mental health in-patients across NHS trusts in Essex between 2000 and 2020. The Government appointed Dr Geraldine Strathdee, a former national clinical director for mental health for NHS England, to chair the inquiry. I want to place on the record my thanks to Dr Strathdee and her team, because a lot of good work has been done. I applaud the bravery of all the victims and their families who have come forward to tell their stories.

I also recognise the work that the Essex Partnership University NHS Foundation Trust—EPUT—has done to assist with the inquiry. The trust has been in the spotlight, and progress has already been made to learn lessons and improve in-patient mental health care. EPUT’s chief executive, Paul Scott, joined in 2020, and since then the trust has invested £20 million in its mental health in-patient wards and a further £20 million in community services. Compared with 2019, patients absconding from care has decreased by more than 60%, and the use of inappropriate restraint has fallen by 88%.

However, in January Dr Strathdee raised concerns with me about a lack of engagement with the inquiry by current and former EPUT staff. I know that many right hon. and hon. Members share her concerns. Since then, the inquiry and the trust have worked together in a concerted effort to increase staff engagement. None the less, I have listened to Dr Strathdee’s concerns that the inquiry still needs further staff engagement to get victims’ families the answers they deserve. In a letter to me in March, she said that

‘30% of named staff, those essential witnesses involved in deaths we are investigating, have agreed to attend evidence sessions. In my assessment, I cannot properly investigate matters with this level of engagement’.

She has also raised with me concerns about ongoing safety issues at the trust. To quote from her letter once again, she said:

‘I am very concerned that there are serious, ongoing risks to patient safety. Due to the nature of these issues, I am confident that these cannot be properly investigated by the Inquiry without statutory powers’.

The Government take both concerns extremely seriously, and I agree with Dr Strathdee that we have now reached the point where the only appropriate course of action is to give the inquiry statutory powers.

Statutory inquiries do take longer, but this does not mean that work will start from scratch. Dr Strathdee’s existing findings will inform the next phase of the inquiry. She has informed me that, owing to personal reasons, she will not be continuing as the inquiry’s chair, so I want to thank her once again for all her commitment and hard work. I am sure the House will agree that she is a true public servant. Our work to find her successor is proceeding at pace, and I will update the House on the progress of setting up the inquiry in due course.

I recognise that Members’ concerns about mental health in-patient facilities are not confined to Essex. The Government are committed to improving mental health care across England, which is why we are boosting mental health funding by at least £2.3 billion this year compared with four years ago, why we are making urgent mental health support available through 111, and why we are delivering three new mental health hospitals to provide specialist care and cut waiting lists.

In January, we commissioned a rapid review of how data is used in in-patient mental health settings in England. More effective use of data has the potential to reduce duplication, ensuring that healthcare professionals can spend more of their valuable time with patients. The review team—well led again by Dr Strathdee—heard from more than 300 people representing every part of the in-patient mental health sector, including former patients and frontline staff. Dr Strathdee has made recommendations for how data and evidence can be used to identify risks to patient safety and failures in care more quickly and effectively. The findings and recommendations of the rapid review will be published today, and I will deposit a copy in the Libraries of both Houses. The Government will consider its findings carefully and respond in due course.

We recognise, however, that patients and families want to know how their concerns will be taken forward as soon as possible, and I also recognise that a wide-ranging statutory inquiry relating to other settings, or covering multiple patient safety issues, would not deliver those answers quickly. My Department has therefore agreed to work alongside the Healthcare Safety Investigation Branch to prepare for the launch of a national investigation of mental health in-patient services, which will commence in October, when the HSIB receives new powers under the Health and Care Act 2022.

The new Health Services Safety Investigations Body will investigate the following themes: how providers learn from deaths in their care and use that learning to improve services, including post-discharge services; how young people are cared for in mental health in-patient services and how that care can be improved; how out-of-area placements are handled; and how to develop a safe staffing model for all mental health in-patient services. Across all those areas, it will explore the way in which providers use data. I want to reassure the House that the new body will have teeth and will work at speed, that it will have the power to fine those who refuse to give evidence when they are required to do so, and that its predecessor’s investigations were typically concluded within a year.

I hope that today’s announcements will be of some comfort to the bereaved families who have done so much to raise awareness of the failings of mental health care in Essex and elsewhere. I want them to know that the Government are committed to obtaining for them the answers that they deserve, and to improving mental health across the country. I commend this Statement to the House.”

My Lords, I welcome the announcement in this Statement that the inquiry to investigate the deaths of mental health in-patients across Essex between 2000 and 2020, chaired by Dr Strathdee, will now be given vital statutory powers. This is an important and long overdue development. Not only have the grieving families suffered the pain and anguish of bereavement, and how they have felt in their fight for answers over so many years, but all of this has been compounded by an inquiry that lacked the necessary powers to seek the truth. It would be helpful for your Lordships’ House if the Minister could shed some light on why it has taken so long to allow the inquiry to do its job thoroughly.

More broadly, and connected with this issue, are repeated scandals in in-patient mental health settings involving abuse, dehumanising behaviour and needless loss of life, such that more than one in three people say they do not have faith that a loved one would be safe if they needed mental health care in a hospital. How will the Government seek to restore essential public confidence?

The situation set out in the Statement is against a backdrop of some 1.6 million people on waiting lists for mental health treatment. Their condition is deteriorating and can reach crisis point. At the same time, the incidence of poor mental health continues to rise. Those in poverty or financial difficulty are particularly at risk, to mention just one group. With the cost of living crisis continuing unabated and children from the poorest 20% of households four times more likely to develop serious mental health difficulties by the age of 11 when compared with the wealthiest 20%, this is an upward and unequal trend that the Government have to tackle. I hope the Minister can comment on how this will be properly dealt with.

I will pick up some particular aspects. Families of patients in Essex will welcome the news that this inquiry will be put on a statutory footing, but across the country those failed by inadequate mental health services are in desperate need of answers and need change. In March 2022 the CQC released its Out of Sight report to identify what progress the Government have made in addressing the culture, behaviour and design of services for patients in mental health in-patient settings. Will the Minister tell your Lordships’ House what progress has been made in implementing the recommendations in full?

If we are to bring about change, it is very important that the rapid review of data in mental health in-patient settings translates into action and the report does not simply sit on a shelf in the department. Can the Minister tell your Lordships’ House when the Government’s response to the review will be published and whether he will set out a timetable for when the recommendations are to be implemented?

Over the past year there has been a flurry of reports, as we know only too well in this House, of patients being failed in the care of mental health trusts around the country. Have Ministers actually met the leaders of those trusts to find out what has gone wrong? If not, do they plan to meet and when?

The Government have shelved the 10-year mental health strategy and, despite promises first made in 2018 to reform the outdated Mental Health Act, legislation has repeatedly been delayed. The Joint Committee on the Draft Mental Health Bill published recommendations for improving legislation in January, but thus far Ministers have still not responded to the report and the Bill is yet to be introduced to the House of Commons. Will the Minister please update the House on when it can be expected?

When it comes to mental health, taking a preventive approach would mean fewer patients needing to use in-patient services in future. Have the Government considered shifting the system towards prevention by providing mental health support in every school, for example, and a mental health hub for young people in every community? Ensuring that there are enough staff to provide adequate services is vital to improving patient outcomes, so can the Minister say some more about what plans the Government have to retain staff, to recruit new staff and to expand access to mental health treatment? I look forward to hearing from the Minister on these points.

My Lords, I am grateful to have an opportunity to discuss mental health provision, and my comments will very much follow on from those of the noble Baroness, Lady Merron. We are also interested in the Government’s latest thinking about the draft mental health Bill. Now that the workforce plan is out—we will discuss it tomorrow—our new refrain may be, “When will the Government get on with the mental health Bill?”. It is long overdue, and a huge amount of work has gone in that is clearly fundamental to trying to deal with some of the structural issues.

Turning to some of the issues raised in the Statement, I first want to ask about people’s journeys when they are in need of mental health support. The Statement said that 111 will now provide mental health advice, which is very welcome, but can I ask the Minister for his thoughts on what is happening in primary care? My understanding is that at the moment mental health nursing provision is not a requirement of all general practices—some offer it and others do not. Can the Minister, who I know cares about joined-up, seamless services, give us some insights into the Government’s thinking on ensuring that people who present with mental health problems to general practice—which is the first port of call for many of them, before they even get to 111 or 999—see more consistency of support available at that level?

Thinking about the review—a major part of what is in the Statement—a significant proportion of providers of mental health in-patient services are private sector, which has been the case for some time. Can the Minister confirm that they will be included in the review and comment on whether the inspectorate’s powers will be applied equally to the private and public sectors? That is critical to understanding what is happening in all settings.

Will the Minister also talk a little about the input the review may get from related services? Again, we know that the police, local authorities and accident and emergency departments often pick up the pieces where mental health provision has not been made available. Can the Minister assure us that the review will also look at all those other parties to this journey of care that people require? Can he also comment on the data questions? I have seen evidence from freedom of information requests to the Office for National Statistics asking about deaths of people in mental health in-patient settings. My understanding is that the data is not recorded consistently. If we are to have a review and to understand what is happening in the mental health sector, it would be helpful to know what measures the Government will take to improve the consistency of data collection so that, when someone unfortunately suffers a tragic incident, we know where they were at the time and have the data available to build up the national pattern.

The final issue I want to ask for the Minister’s comments on is out-of-area placements. Will he acknowledge that it remains a serious issue that many people with serious mental health conditions are able to get treatment only in places that are far from home and therefore far from their families and support networks? I note from the Statement that the Government are providing three new hospitals. This is of course welcome, but I hope the Minister will also be able to confirm that there is a locality-based strategy, with the Government thinking hard about matching local facilities to local need so that we can end the situation in which people at a time of extreme distress are sent very far away from home, which can only add to the crisis they are facing.

I thank noble Lords for their questions and their general welcome for the Statement. On timing, we had hoped that doing it on a non-statutory basis would have been sufficient. The advantage is that you get the results that much quicker; you can often get them within a year, versus three years. We have many examples of where it has worked quite well, such as the Kirkup report. To answer the question of why it is taking so long, in the first place we had hoped that doing it on a statutory basis would not have been necessary. There was a course correction in January, when we were not getting the response we needed and not enough staff were making themselves accessible. There was some improvement at that point, but it was felt by the chair that it was not sufficient, hence the decision now.

We believe that we can build on the work that has been done so far, so we are not starting again from zero. However, there are some lessons. On a number of occasions, trusts and staff have responded well to a non-statutory inquiry, but we have learned from this that sometimes it needs to have the teeth of a statutory inquiry so that it is taken seriously enough. Somehow, there was an impression that, because the inquiry was not statutory, it was not seen as serious enough to trigger that. There is a key lesson to learn from all of that.

How we can seek to restore confidence is absolutely the right question to be asking. We believe that the additional investment of £2.3 billion that we are putting into this space is a key part of that, and the increase of 27,000 staff is another. We are learning from the reviews that we are doing, and we are quickly learning from the rapid review. We are working fast, so I cannot give an exact date for those results. We asked for it to be a rapid review so that we could get on with it and make the most of the findings.

The other key part of this is the Healthcare Safety Investigation Branch. We are asking it to look into a number of questions, one of those being out-of-area in-patients and the impact that has. I think we all agree that it is best if people can have in-patient services locally. That is one of the key parts that it will be asked to review. On the timing of that review, it will start in October and should be able to conclude within a year. We should get results back quite quickly.

On the timing of the mental health Bill, we are working through the parliamentary calendar now. We do not know the timings yet, but the scheduling is being looked at.

The noble Baroness mentioned the prevention agenda. I completely agree that care in the community and the training of staff in GP settings and schools are vital to this. As noble Lords have heard me say at the Dispatch Box before, we are making good progress: about 35% of schools are trained up in mental health support. Last year it was only 24% and next year we think we will be pushing 50%. Those are big increases, but I freely accept that 50% is not 100%. A lot of progress is being made in that area but we accept that a lot more needs to be done.

As for the private sector being included in the review, I have every reason to think that it should be and that there should be equal powers, but I will check that. I am talking off the top of my head now as it seems perfectly sensible, but I will come back properly on that.

I will do likewise with the comments on the recording of and use of data. Again, one of the rapid review findings was that we do not have enough real-time data. That is very much the direction of travel but, again, I will come back with more detail. As ever, noble Lords will know that I like to bring all these things together in a lengthy letter where I hope I am able to cover any points I did not cover here.

There are steps in the right direction, and the investment I talked about is another step in the right direction. I completely agree with the emphasis that it is vital we restore confidence in this area.

My Lords, I would like to begin the questions, as chair of the recent Joint Committee on the Draft Mental Health Bill. I say to my noble friend the Minister that we accept—I accept, certainly—that this Government are committed to improving mental health care across England. However, there is a strong sense of disappointment. Having published this report on 15 January, after a huge amount of work—I am proud to say it was an incredibly collegiate cross-party committee, across both Houses, and we came up with 55 recommendations with great care—we have had one short note from the Minister in another place, Maria Caulfield MP. It said that there was much consideration going on, and obviously both the Department of Health and Social Care and the Ministry of Justice are involved. The note said the response was in an advanced state and that we would be hearing from her in due course. However, we are now in July.

I believe it is hugely important that the Government demonstrate, rather more than they have so far, their commitment to improvements across the piece in mental health care. We are in a good place on support, but that support will wane unless the Government can really show commitment. I know there is an issue with the parliamentary timetable and so on, but the Government could at least respond to our 55 recommendations.

In addition, I have suggested to the Secretary of State a couple of things that could be done prior to legislation—in fact, a number of things in our report could be implemented without primary legislation. For example, on 26 February, I was actually quite unwell but I still met some civil servants at the Department of Health to discuss an incredible app that has already been developed for the palliative care world to support people in crisis. This app could be easily translated at very reasonable cost to support people having a mental health crisis. I was accompanied by—

A question is coming. I was accompanied by a brilliant consultant, Julia Riley. She has not even had a cursory note of thanks from those civil servants. Could the Minister therefore please respond by giving a little more detail on the timing? Could he also let me know whether there has been any progress on developing that particular app? I would also like to know about the implementation of safe places, where people can go when they are in crisis.

I thank my noble friend for her tireless work in this space. We believe that a number of constructive points were made in the committee report, which I know Maria Caulfield is working on and looking to get a timely response to. Maybe that is something on which we can meet up and discuss later.

My Lords, I raise the issue of the mental well-being of men from black and Asian backgrounds. I particularly raise the issue of the care they are receiving at the hands of very poorly qualified, untrained, unsympathetic people, who do not adequately understand the complexity not just of mental health and well-being but the way that they should be operating. They are not working in tandem with the families, which is one of the requirements. There have been suggestions from a number of community organisations that black and Asian men are four times more likely to be detained, and sometimes it is more than likely that there has not been any consultation with their families, which is one of the prerequisites. Can the Minister assure this House that any formal forward-thinking and examination of these issues is looking at the disproportionality of the effects and the causes of very poor services, particularly for men from black and Asian minority backgrounds?

Yes, we are very aware of the points made very well by the noble Baroness, including some of the stats on the community treatment orders and the fact, I believe, that if you are a black male, you are eight times more likely to be detained. I know that that led to some of the recommendations from the pre-legislative scrutiny committee. I can give an undertaking that that will be fundamental to what we are trying to do here.

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

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

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

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

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

My Lords, the Government’s draft mental health Bill proposes—and I and the Joint Committee support this—the banning of prisons as a place of safety and the transfer of patients within 28 days of the mental health assessment to a safe mental health secure unit. Will the Minister ensure that this is included in the national review, so that there are sufficient local safe secure facilities to implement the 28-day recommendation and that these patients are cared for in genuine places of safety?

I understand the concern brought, quite rightly, by the noble Lord. It would be best for me to write on that, so that I can give the specific position and he can have the detail he requires.

My Lords, I am a member of the Joint Committee. We heard compelling evidence from the Independent Advisory Panel on Deaths in Custody that, although there is always an inquest into an unexplained death, there is the unique situation where if you die detained, in effect, by the state but in a secure mental health institution—as opposed to a prison, police cell or immigration detention centre—there is no independent investigative body to investigate the circumstances around your death. Given that this independent inquiry will look at a series of deaths over 20 years, will it be within its remit to look at whether or not, had there been some kind of independent investigation of those deaths, the themes and problems faced by the trust might have been spotted earlier?

We see that as being very much in the remit of the Health Services Safety Investigations Body. In fact, the first thing we are asking it to do is to consider how we can learn from those unfortunate deaths, where they have taken place, in terms of their care. The intention is that it will report back. It will start in October and will report back on that within a year, so that we can get some rapid findings.

My Lords, can the Minister return to the contribution from the noble Baroness, Lady Watkins? I note that the HSSIB has been asked to look at and develop a safe staffing model for in-patient services, but I re-emphasise the point made by the noble Baroness: you cannot look at in-patient services only; you have to look at the whole spectrum. Surely, he accepts that. For instance, with young people, the huge waiting times for CAMHS services, which eventually lead to some of them being out-of-area placements, is shocking. Surely, HSSIB should be looking at the whole picture. Can he also say how this will relate to the workforce plan? In other words, will the conclusions of HSSIB’s report go forward into the workforce plan, so that for the future we are developing enough people in the mental health field?

As I am sure the noble Lord is aware, the second thing that the HSSIB is being asked to look at is exactly the point about how people are cared for as in-patients and how we can improve that approach. On staffing—again, we will debate this more tomorrow night following the Statement repeat—it is vital that there is a feedback loop in terms of the long-term workforce plan. That feedback loop, as I am sure noble Lords are aware, is built into it, so that when new data comes along, as will potentially be the case with the HSSIB, there is a way for that to feed back in again.

My Lords, I will follow on from the point made by the noble Baroness, Lady Berridge. Until 2015, I chaired the Independent Advisory Panel on Deaths in Custody, which covered the more high-profile areas of deaths in police and prison custody. However, the largest number of deaths under the care of the state was in mental health institutions. The noble Baroness, Lady Berridge, asked about independent investigations and the Minister said that the review will look at what lessons can be drawn. The point is, however, that over the last 20 to 30 years, there have not been independent investigations into the individual deaths, so how will there be an evidence base to decide whether proper lessons were drawn at the time and whether those were acted on?

Secondly, my noble friend Lord Hunt of Kings Heath talked about the difficulties with CAMHS. There is a gulf at age 18 between people being treated under CAMHS and then going into adult mental health services. What are the Government doing to bridge that gap? People who may have received some support from CAMHS then lose it when they go into the adult sector.

Finally—I know I should not ask three questions, but I want to—one of the striking things about the number of deaths that occurred in mental health institutions is that many arose from physical causes. It was not about people committing suicide or their mental health crisis; it was the fact that in a hospital, a place of medical provision, they were not getting adequate physical healthcare. What are the Government doing about that?

I thank the noble Lord for his commitment in this area over the years. With regard to the first question about past evidence, clearly the HSSIB will be looking at what evidence exists. As the noble Lord said, some investigations go back 30 years, so there will not always be circumstances where it can pick out that evidence, unfortunately. However, where there is that information, we are trying to make sure that we pull it out and learn from it. That is very much the direction of travel. Clearly, if part of the HSSIB’s findings is that we need to make sure that every death in such circumstances is investigated under a certain pathway, then I am sure that will come into its recommendations. In terms of the other questions, I think it is best that I write to the noble Lord, if I may.

My Lords, the Statement includes a number of themes which it is expected the new Health Services Safety Investigations Body will consider. Not included in that list, however, is the growing role of private provision in NHS mental health care services. This is something that patient groups and others are expressing considerable concerns about. Take, for example, the Priory, where the Care Quality Commission reported that the number of deaths at its sites rose nearly 50% from 2017 to 2020. One of those was the tragic death of 23 year-old Matthew Caseby. An inquest jury concluded that his death was contributed to by neglect, and the coroner issued a prevention of future death report because of continuing risks.

The Priory Group earns more than £400 million from the NHS, and much more from social services. It is now owned by a Dutch private equity firm after it was sold by its former owner at a loss and is financed by a sale and leaseback deal of 35 properties with rents subjected to annual inflation-based escalators. Through the mechanisms in this Statement or others, are the Government going to consider the risks presented by private ownership—particularly private equity ownership—of mental health care services?

As noble Lords are aware from some of my previous answers, I think the key thing is the quality of output rather than the ownership of an institution. Around the House, we have very good examples of where we believe the Government need the help of the independent sector to increase supply and capacity. That always needs to be done with the right quality of regulatory regime, and that is what we have put in place. From my point of view, I am always going to be looking at the quality of the output and not the ownership of a company.

My Lords, on the Minister’s last observation, I think there are a number of noble Lords here who would say that the quality of the output has not been that great from some private providers. It is just an observation.

However, the question I want to ask will take us back to the original observations by the noble Baroness, Lady Buscombe—I was also a member of the Joint Committee. The Minister gave a very brief reply to her questions about what has happened to the many recommendations, the vast amount of evidence and a great deal of hard work that went into producing that report. He even mentioned that it was going to be responded to in a “timely” manner. I think the moment for that has passed. Will the Minister have another go at explaining what has happened to the report and when there will be a response to it?

I am afraid I do not have the timing of a response on that. Minister Caulfield is very engaged in this area. A number of things have been mentioned. I mentioned the community treatment orders, where we are very mindful of the point made earlier by the noble Baroness, Lady Uddin, about black males being eight times more likely to be given one, and the recommendation that they should be abolished altogether. Those recommendations are very much in our thinking and our knowledge base. I know that Maria Caulfield is working on them, but I am afraid I cannot give the noble Baroness an exact time yet.

Sitting suspended.