Health and Social Care Bill

My Lords, I believe that I speak with some authority in proposing this amendment as a former chair of the Mental Health Act Commission and one who has worked for many years as a practitioner, manager and researcher in the field of mental health. Many noble Lords are also familiar with the particular needs of those with mental health problems and we have already debated some of the key issues and omissions in the Bill with respect to mental health. Although the noble Earl has been understanding and generally supportive, we have not yet seen any movement by the Government on issues such as ensuring parity between physical and mental illness. I sincerely hope that we will see some movement with respect to this clause because I am in no doubt that it will have the effect of reducing the quality of service and safety to some of the most vulnerable people in our society, those who have been detained under the Mental Health Act. On the surface, Clause 37 appears quite reasonable. It seeks to amend Section 117(2) of the Mental Health Act 1983 in order to transfer duties that currently sit with the PCT to the newly created clinical commissioning groups. Section 117 concerns the provision of aftercare services. Aftercare services for this extremely vulnerable group of patients are absolutely vital. They consist of a range of services in a single care package. Some examples are visits from a community psychiatric nurse, going to a day centre on a regular basis, befriending and support services and having medication, counselling and supportive accommodation. Everyone with mental health needs is entitled to a community care assessment to establish what services they might need. However, Section 117 of the Mental Health Act at present goes much further and imposes a duty on both health and local authorities to assess and provide aftercare services to patients who have been detained under a variety of sections from the 1983 Act. That means that these agencies are under a joint duty to provide aftercare services free of charge until both NHS and local authority commissioners agree that the service user is no longer in need of such services. However, the real problem here—and it is a serious one—is that Clause 37 does more than transfer these duties to the clinical commissioning groups. In effect, it significantly alters these duties so that the protections currently afforded by the Mental Health Act are greatly weakened. Separating the statutory responsibilities between CCGs and local authorities in the manner proposed by Clause 37 will allow one agency to decide to end the provision of services without notice or consultation with the other agency or even the patient. The duty established by Section 117 of the Mental Health Act was applicable to the ongoing care of roughly 18,000 people discharged from detention in hospital last year alone. I should point out that this included over 3,700 people discharged on to a community treatment order, thus making a total CTO population of approximately 6,000 people. People on a CTO can be required by law to accept forms of treatment and care that amount to aftercare, and they equally deserve and need the protections currently afforded to those patients leaving hospital. There are three things about Clause 37 that concern me most. First, it removes the duty of co-operation on delivering aftercare services between the health service, the local authority and the voluntary sector. Secondly, it turns what is currently a free-standing duty into a gateway provision, which will restrict the scope and effect of aftercare services. Thirdly, as a consequence of this, it provides a back-door route by which aftercare services for detained patients will become chargeable. I will start with the duty of co-operation. Clause 37 has the following effects. First, with respect to Clause 37(2)(c), (e) and (f), the joint duty to provide aftercare services is split between health and social services authorities. Each can separately decide when to withdraw its own services without requiring the agreement of the other. Secondly, at line 8, page 73 in Clause 37, CCGs will no longer be under a duty to arrange aftercare, "““in co-operation with relevant voluntary agencies””." I am sure that my noble friend Lord Adebowale will say more on that subject. This is not about general health responsibilities or duties. It is about fundamental recognition of the impact of being detained under the Mental Health Act. For example, on leaving hospital after a prolonged period of detention, a person is likely to have lost their accommodation and will be in need of somewhere safe and appropriate to live. They are also most likely to be feeling very vulnerable and low. During their period of acute illness they may have offended or alienated family, friends and neighbours. They may be particularly vulnerable to abuse as a consequence of the stigma of having been detained and, while they may certainly be recovering, they will not be better. They remain in need of treatment whether through medication, counselling or both. None of the after-care services that they will need will be effective on their own. These services work and thus prevent readmission to hospital or worse because they are joint and co-ordinated, which means that neither authority can unilaterally decide to remove an element of their after-care package without the agreement of the other. Most importantly, they are also required to work collaboratively with the voluntary sector on these arrangements. This means that a local authority cannot decide that it can no longer afford to provide the funding for supported accommodation in the voluntary sector and unilaterally decide to withdraw from the arrangements. In the current economic climate, it seems to me that that scenario would become likely if the clause is passed as part of the Bill in its current form. It is absolutely certain that there will be greater scope for dispute between the various authorities and the voluntary sector, which will be left ultimately responsible at the end of the day. We need think only of the burden of the expenditure cuts in health and social services to realise that that will be the case, as both CCGs and local authorities seek to restrict their services. The patient will be left to play piggy in the middle, and it is often the patients, their carers and their families who will suffer the most. My amendment would retain the joint duty on CCGs and social services authorities. It would also ensure that CCGs continue to arrange for provision of services under Section 117 of the Mental Health Act, in co-operation with relevant voluntary agencies. But it is not just the potential loss of co-operation and shared responsibility for care that is at stake here. My other two concerns are with respect to the fact that the current protection afforded by the duty to provide after-care services is a freestanding duty. Clause 37 fundamentally changes this. First, it states that CCGs’ duty to commission health care services will be limited to services of a kind that must be provided under Section 3 of the NHS Act 2006 or may be provided under Section 3A of the NHS Act. This removes the clear and unambiguous responsibility on PCTs and local authorities to provide appropriate after-care services. The current wording of the clause has the effect that the duty to provide after-care falls only on CCGs and, as such, will be only for health services, not social care services. By definition, after-care services must go beyond those provided by health alone, as they involve all the things I have already mentioned with respect to picking up your life after being detained—housing, counselling, befriending and advice, alongside the traditional health treatments and support. The wording is insufficient to ensure that these protections continue, and it clearly alters the nature of what was a freestanding duty to make it a gateway provision. Secondly, Clause 37 states that Section 117 will be treated as a duty under Section 3 of the NHS Act 2006 and will be provided under the same duties as other healthcare. By removing the freestanding duty and making duties to provide after-care for detained patients the ““same duties as other healthcare””, Clause 37 opens the way for charging for after-care services. For example, a potential effect of the clause is that it would allow for means-tested charging for such services as care home fees. They are currently exempted on the grounds that having detained a patient the state owes something of a reciprocal duty to provide after-care and that charging for such services would therefore not be acceptable. I spoke of this at Second Reading, when I reminded the House of the judgment made in this very issue in the Stennett case before the Appellate Committee of this House. Let me remind noble Lords of this landmark judgment more fully. The exact case concerned Manchester City Council and two other councils, which appealed High Court rulings that they could not charge for the residential care of patients who had been discharged into such care from detention in hospital. Mr Stennett was one of those three patients. The judgment was made on 25 July 2002. In essence, the case established that Section 117 established a freestanding duty to provide after-care and that, as it contained no charging provisions, no charge should be made for after-care under that section, including for the provision of residential accommodation. The argument that this was in fact a gateway provision, whereby other statutory protections would be triggered was completely rejected by the appellate court. I hope that the noble and learned Lord, Lord Steyn, will forgive me for paraphrasing his judgment in the case, but in essence what he said was that if it had been the intention of Parliament that Section 117(2) of the Mental Health Act would be a gateway provision, by which other statutory provisions were triggered, it would have specified what those provisions were. More importantly, if it were a gateway provision then it would require appropriate wording. The noble and learned Lord, Lord Steyn, said in summary that, "““Section 117 is free-standing. It imposes a duty on the authorities to provide the after-care services and to continue to do so ‘until such time as . . . the person concerned is no longer in need of such services’””." If I am not mistaken, I believe that the noble and learned Lord, Lord Mackay of Clashfern, was part of the panel of judges that agreed with that judgment. The importance of this being a free-standing duty is that the relevant authorities are required to sort out the funding for the package of aftercare between them. Furthermore, one of the greatest issues in ensuring that aftercare services are effective is securing the agreement and co-operation of the patient. This is known to work best when aftercare services are free and seamless. The current protections afforded by Section 117 represent best practice for vulnerable patients with mental health problems as it ensures that there is a joint support with a package of integrated services. The requirement that, once in place, this joint package of care cannot be broken without everyone's agreement means that patients are more likely to get access to the services that they need for as long as they need them. My amendment seeks to ensure that the arrangement of services by CCGs under Section 117 is not limited to services arranged under Section 3 or Section 3A of the NHS Act, by deleting the proposed new subsection (2E). In addition, the amendment will ensure that the duty on CCGs will not be regarded as a duty under Section 3 of the NHS Act. This means that it remains a freestanding duty under Section 117 of the Mental Health Act. I am grateful to the Law Society and to Mind, which have helped in preparing briefings on this amendment and the key issues at stake. In addition, the Law Society has obtained independent legal advice on the specific implications of the current wording of Clause 37, which leaves me in no doubt that my concerns about this aspect of the Bill are justified. It is clear to me that the impact of Clause 37 would be to make a very vulnerable group of patients more likely to fall between the gaps created by the confusion and scope for dispute that it will create. Moreover, it strikes me that removing this protection goes against the ethos and promise of this Bill, which is for more, not fewer, integrated services. The joint duty on health authorities and local authorities to provide health and social care, coupled with the fact that Section 117 is a freestanding duty to provide aftercare, effectively prevents either health authorities or local authorities charging for such services. I believe this to be necessary and a vital protection for this vulnerable group of patients. I sincerely hope that the Minister will see the necessity of this amendment and agree that it seeks to ensure that vital protections for some of these patients remain in place. Most importantly, I hope that he will accept that this House should not allow the possibility of charging as an unintended consequence of this change in statutory wording. Clause 37 reverses that ruling by the House’s Appellate Committee—or has the potential to do so—by taking such matters as domiciliary care, not directly linked to health provision, out of the scope of Section 117 of the 1983 Act. This potential reversal would appear to have been suggested without the matter being debated in Parliament at all. For that reason alone, surely the current clause cannot stand. I beg to move.