Contribution
I will speak to Amendment 100 in this group, and there are four or five consequential amendments which I have added. Noble Lords will therefore be pleased to know that the group is a lot smaller than it looks.
The purpose of this amendment is, on the face of it, to remove informal patients from qualifying for help from independent mental health advocates, on the basis that, given the resources required, to expand the services for detained patients to all in-patients is impractical, as in the impact assessment done by the Government. There will be some who assume from this amendment that I do not like IMHAs, but nothing could be further from the truth.
On the face of it, one cannot criticise what appears to be an extension of services and automatic referral to IMHA services, for both detained and informal patients. Local authorities, under direction from Schedule 3, will be obliged to provide the service and will need to extend it significantly. There are currently 50,000 new detained patients eligible for the service every year, but this would double to 100,000 people when informal patients are included. The impact assessment for cost to local authorities calculated that these new services will be an extra £571 million over a 20-year period—that is over half a billion pounds, or £81 million or so every year.
One might assume, therefore, that some serious evaluative research had demonstrated what a boon advocates are, as we all hope so, and that patients valued them and that they made a big difference to their outcomes. However, there is just one small UK study, by Karen Newbigging and her colleagues, which, on quality of services, suggested that where they were accessible— and they were not really very accessible in all the places studied—patients found the process was a positive experience, although they had no impact on outcomes of care and treatment. The advocates concentrated on explaining people’s rights but did not advocate more creatively to change decisions on care, which the authors rightly suggested could be an important role.
It is generally thought that, where IMHAs are from the same ethnic community as the patient, this is one step that could be taken to make the service more friendly for black and other ethnic-minority patients. There is better evidence in the States, where it has been demonstrated that independent advocates are central to the success of advance choice documents; patients do not create advance choice documents without a facilitator. A study in North Carolina showed that providing a facilitator in the form of an independent advocate increased the number of people making a psychiatric advance directive from 3% to 60%. Since we hope that these will be increasingly helpful to patients, I can understand why we think it is very important that detained patients should have them.
However, I would suggest that it is a bit of a leap to go for a massive expansion without much more evidence on how best to use these trained advocates and on who benefits the most. In September 2023, there were 28,600 vacancies—19% of the total workforce—in mental health services, including 1,700 medical and 13,300 nursing vacancies. In spite of training more staff, there is ample evidence that the current challenges posed by in-patient environments mean that many services rely on agency and bank staff simply to keep the ward open. The King’s Fund survey of approved mental health professionals found that, to meet the requirements of a 24-hour service, there would need to be a 30% increase in the number of full-time equivalent staff, in addition to accounting for the vacancy rates of over 11%.
Yet here we are proposing that the local authority should spend a huge amount of money on independent mental health advocates, when it does not have a satisfactory number of psychiatric social workers and cannot fulfil its obligations to provide decent social care for older people or protect vulnerable children from harm. If any noble Lords were reviewing their own local authority spending, do we seriously think that expanding IMHA services to informal patients would be high on the agenda? I think probably not, although I believe they will be helpful, especially for patients matched to someone of the same ethnic background. I would like to see more consistent evidence about how best to recruit and train them and develop their skills because it is crucial, if we do fund them, that we get the basics right, so that when they do get appointed, they are doing the right things for the right people. Otherwise, we should be extremely cautious in expanding these services.