Committee stage in the Lords
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Baroness WilkinsLabour- Quote
- moved Amendment No. 7:
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Lord Williamson of HortonCrossbench- Quote
- I support Amendment No. 7 and to shall speak to Amendment No. 55 tabled in my name and that of my noble friend Lady Meacher. These amendments are rightly grouped together as they have broadly the same aim. Indeed, the amendment moved by the noble Baroness, Lady Wilkins, is the Rolls-Royce of these amendments and mine is the Mini, but we are both driving steadily in the same direction. The purpose of these amendments is to put into primary legislation a right to a comprehensive assessment of the need for support and treatment for those who have or have had a mental disorder and are not in hospital. I draw attention to the fact that the assessment would be the responsibility of the local authority and, I believe for the first time in this form in statute, of the NHS body. The responsible authorities, having regard to the results of the assessment, then have to decide whether the requirements of the person call for services of support and treatment and, if so, to make the necessary arrangements. We think that this is highly reasonable. It is after all not so different from what might happen in the case of physical illness. It is a straightforward way of approaching the system, and it can be summed up as meeting the objectives of: get in early, do not wait for compulsion and do not leave a condition untreated. That is what happens now and what we want to avoid in the future. The Minister will not be surprised to hear me say—and not for the first time—that this proposal is in line with the Scottish mental health Act. If Scotland can produce one Prime Minister after another, I am sure it can produce good legislation as well. In addition to the evident value of assessments, in the case of mental disorder we also believe that it could remove or reduce the number of cases where people are turned away from services when they seek help. We all know that this is a tragedy which happens quite often, and the results are unforeseeable and usually bad. A survey undertaken in 2003 by Rethink—I declare my interest as a patron and long-time supporter—showed that up to one person in four was turned away by services when they or their family sought help. There are some differences between Amendments Nos. 7 and 55. For example, the proposal by the noble Baroness, Lady Wilkins, has a much fuller statement of treatment and support in subsection (10), while Amendment No. 55 includes a specific provision requiring the health authority and the local authority to give reasons in writing if they do not intend to carry out an assessment. This is intended to avoid an unwanted silence, which as we know sometimes happens in the treatment of mental illness. Amendment No. 55 also specifically refers to the possibility of requests by the person himself or herself, the carer, the nearest relative or an approved mental health professional. It is a little more specific in that respect. However, it is fair to say that if the Government accept the amendment proposed by the noble Baroness, Lady Wilkins, all will be well. If not, and the issue comes back on Report, it is probable that there will be a single amendment and not two, as we have before us today. But the objective, of course, will be precisely the same.
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Lord Carlile of BerriewCrossbench- Quote
- I support both these amendments. As the noble Lord, Lord Williamson, has said, they aim to achieve the same purpose. In so doing, I should like to reflect for a few moments on my experience when I was a Member of another place. I recall being involved in two non-mental health areas or schemes which were extremely successful. One concerned raising money for a CT scanner to be based in a hospital in the region in which my then constituency was situated. It was what I think the press would call a rather sexy scheme. It was possible to raise the money quickly; it was a large amount of money—a seven-figure sum was put together, and the scanner was installed. Afterwards it transpired that not enough staff were available to operate the scanner at all the times when it was needed. That was a managerial problem which left one feeling a little disappointed with one’s achievement. The other organisation I was involved with was a truly wonderful place, a children’s hospice of which I was a trustee for a time. The hospice in question, perhaps like all children’s hospices, had no statutory funding at the time, but it appealed strongly to the local community. I recall going to one meeting of the trustees on a Saturday morning and being told that we had a serious problem. The serious problem was that we had raised so much money during the previous two months that other charities in the region were complaining bitterly and we had to put a brief moratorium on the raising of funds for the hospice. I move on to mental health provision. I was at one time involved in the starting-up of a small regional mental health charity which continues to provide services very expertly for a small number of mainly young people recovering from serious mental illness. When it started we were unable to obtain any statutory funding, and when I ceased to be a trustee at the beginning of last year it was still unable to obtain statutory funding and depended entirely on voluntary contributions, most of it raised from families with some experience of mental illness themselves. It was therefore a very different area for fundraising from collecting the money for a CT scanner or for a children’s hospice. That experience confirmed my view, when comparing it with the others I have described, that mental health provision, particularly that for children and adolescents, remains a Cinderella service. Of course I accept, and no doubt the Minister will tell us, that the Government are doing what they can in many areas to provide better mental health services, particularly for children and young people. But as we heard the other day in what perhaps I may say with respect was an extremely eloquent speech by the noble Lord, Lord Ramsbotham, there are areas, particularly custodial settings, which remain not merely Cinderella areas, but almost completely unclothed. The possibility of those suffering from poor mental health in prisons, especially young people in custodial institutions, reaching the relative ball of a decent child and adolescent mental health ward is still remote, as I am sure the noble Lord would agree. How do we remedy this? How do we, as a responsible society, show those who are mentally ill and their families that we are really taking this issue seriously? A simple and actually inexpensive way of doing it is to have some kind of charter of rights. What is set out in these amendments, taken together and separately, is in effect a very simple charter of rights. As has already been said so well by the noble Baroness in moving her Amendment No. 7, it represents good value for money. A comparison can be made here with the criminal justice system. In 1996, the Audit Commission produced a memorable report on crime committed by young people. It found that £1 invested in 1996 on preventing crime for young people saved approximately £7 later on, so that is money well spent. Exactly the same applies to mental health provision. Beds in acute mental hospitals are extremely expensive. When I visited one of the leading psychiatric hospitals in the country, I was told that for the most acute beds—this is at 2006 prices—the annual cost was £140,000. Occasionally it was double that because of the intensive nature of the care needed. Were we to have this kind of charter of rights for those suffering from serious mental illness, it is self-evident that we would save money in the long term. Are there precedents for this kind of charter? For those who are charged with crime, many of whom are guilty—statistically about half of them are found guilty if they contest their cases, and something like 95 per cent are guilty because most plead guilty in any event—we have the European Convention on Human Rights. This is a very simple document, a small pamphlet, which has been incorporated into United Kingdom law by the Human Rights Act 1998. Many of the people who commit crime have full control over what they are doing at the time they commit the crime. Although many are mentally ill, many are not. The wisest, cleverest, craftiest, most devious of criminals understand exactly what they are doing. In the area we are talking about, a very small number of people have a complete insight into what is happening to them. Some do, of course, but many do not. To introduce a charter of rights in this area is the least a civilised democracy should be offering to people who may be suffering from severe mental confusion. Furthermore, how many people who are sectioned today really understand what their rights are at the time when they are sectioned? I suspect that the true answer is almost none. How many of their families understand what their rights are when they are sectioned? The families become very savvy after a time but, to begin with, the answer is probably virtually none. If we are going to take one opportunity in a generation to introduce amendments to mental health law in this area of serious mental illness, one of the biggest changes we can make, which would be entirely beneficial and would set a new standard for the future, would be to incorporate a short charter of rights into the legislation.
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Baroness MeacherCrossbench- Quote
- In my view, one of the most cruel injustices in this country is the failure of our National Health Service to provide the same level of assessment and treatment to people with mental disorders as we take for granted for those with physical illnesses. This injustice, of course, affects both primary and secondary services. Either of Amendments Nos. 7 or 55, by providing a right to assessment, treatment and support for people with mental health problems in England and Wales, could ensure that progress is made to put right this wrong. If we go to our GP with physical symptoms, whether a skin rash, breathing problem or pain, which our GP is unable to treat effectively, we can expect to be referred to a specialist for a skilled assessment and appropriate treatment. If, however, we go to our doctor with depression or anxiety, which may cripple our lives—these are not minor matters; they can destroy our family relationships, our friendships and our capacity to work and, indeed, may ultimately lead to suicide—we may be turned away with little or no help. Only one in four of those who suffer with depression or chronic anxiety is receiving any kind of treatment. This failure to treat is not only a waste of people’s lives, it is also costing a lot of money to employers and taxpayers, as has already been indicated. Many people with mental health problems are in work but their productivity is much lower than it needs to be. Employers are paying huge sums of money in sick pay for people who could work with a small amount of help. A million people are not working at all and are receiving incapacity benefits because of mental illness.
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Lord SoleyLabour- Quote
- I come to Amendment No. 7 from a very different position from those we have heard about so far. I have heard the arguments about patients’ rights, and I agree with those. I have a history of supporting patients’ rights, and I will go on doing so. One of the things that make this area so incredibly difficult to legislate on, however, is that there is a balance of rights. Rights are not a one-way street. There are also the rights of the people immediately affected by the patient and the rights of the community in which they live. I shall say a little more about that, not only because it is relevant to the nature of this clause, but also in the context of my criticism that the Government’s approach on this does not go far enough. We are not facing the difficult question of what you do when an individual, whether through a personality disorder or other problems, is frightening and difficult for the community to deal with and yet there is no willingness to treat them. That is what this is about. I want to take the Committee back a bit. I touched on this when I made a relatively short contribution on Monday. In the period prior to the 1959 Act, our hospitals acted in a way as containment centres.
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Lord Hunt of Kings HeathLabour- Quote
- I think the noble Lord is speaking to the next amendment. The amendment we are discussing at the moment is on the issue of the provision of services, not the issue of treatment.
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- Lord SoleyLabour
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- My apologies if that is right. I was reading Amendment No. 7 and some of the subsections of the new clause deal with treatability. Is that not right?
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Baroness Royall of BlaisdonLabour- Quote
- This amendment is about rights to support and treatment.
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- Lord SoleyLabour
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- My noble friend is absolutely right. I apologise; I was looking at Amendment No. 7.
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Baroness MurphyCrossbench- Quote
- If the speech of the noble Lord, Lord Williamson, was a Mini, and that of the noble Baroness, Lady Wilkins, a Rolls-Royce, mine will be a tricycle. I was just beginning to agree with everything the noble Lord, Lord Soley, was saying. I am disappointed that he stopped. I support those parts of the amendments that relate to the demand for an assessment of proper needs and the duty to respond appropriately. I am surprised that so far the name of Marjorie Wallace has not come up in our debates. The campaigning journalist and founder, chief executive and now, I think, president of Sane has pointed out over and over again the cases that come to her of people who sought help and could not get it. That has happened on innumerable occasions. I think of the tragic case in the East London and The City Mental Health Trust two or three years ago, a case with which the noble Baroness, Lady Meacher, will be familiar. One that really came home to me was the sad case of Andrew Robinson, the vicar’s son in Devon, who committed homicide against another Robinson, an occupational therapist from a different family. I have seen the letters from his desperate parents, over a period of weeks and days before he was seen by the psychiatrist, to the director of social services, to the psychiatrist, to the psychiatric social worker, to the occupational therapist—and he was not seen. The outcome was that he was admitted into hospital in the most appalling state of psychotic illness, and he murdered while in the unit. It is worth remembering, when we are talking about detention, that a significant proportion of homicides sadly occur inside psychiatric units. Such cases bring home to you the need for these amendments, I scratched my head and thought, “Oh dear, obligatory services—the Government won’t like that”. But then I thought that we do that all the time for people with physical health problems. The example that springs most readily to mind is the obligatory two-week response for cancer waits. Now, if a GP suspects that someone has cancer, he has a hotline to the hospital and he can demand that that person is seen within two weeks. I think the Minister will accept that on the whole there has been a remarkable response by services in delivering that target. There are glitches, but on the whole it has been a success. It can be done, and it would immeasurably improve the confidence of caring families and individuals to know that they had a right to ask for help when they felt that things were going wrong. I support the amendments.
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Baroness Finlay of LlandaffCrossbench- Quote
- I shall intervene briefly to support these amendments, particularly Amendment No. 7, which outlines comprehensive assessment in a comprehensive way. I understand that the Government have been looking at comprehensive assessment, and that Warwick University has been working with them on it. Amendment No. 7 should not come as any surprise at all to the Government. It is holistic; it looks at a person’s need from the perspective of health and social care. It addresses the tragic situation we hear about only too often, of people wanting help and being turned away.
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Earl HoweConservative- Quote
- We have heard some compelling speeches in this debate. The noble Baroness, Lady Wilkins, and the noble Lord, Lord Williamson, are to be applauded for all that they said in support of their respective amendments. In a policy context it is always problematic to talk in terms of a completely demand-led service available as a right to whoever asks for it. That appears to be the effect of the noble Baroness’s amendment, and I suspect the Minister is likely to balk at it. In his shoes, I probably would as well. Even if I cannot support her amendment quite as worded, however, I am definitely with the noble Baroness in spirit. I am also definitely with the noble Lord, whose amendment seems to me to have the edge over that of the noble Baroness. There are several things that both the noble Lord and the noble Baroness said that bear underlining. The first is that all too often the only reason that someone ends up being subject to powers of compulsion under the Mental Health Act is the lack of available outreach or early intervention services appropriate to their needs at an earlier stage. I was staggered to see the figure from Rethink that 50 per cent of people subject to compulsory treatment have previously asked for help and been turned away. That chimed in with the story that the noble Baroness, Lady Murphy, told us, and it is a terrible indictment of the way mental health services are configured. If anyone supposes that it can be better or more cost-effective to treat someone as an in-patient under conditions of coercion than to provide treatment to the person informally when they are much less severely ill, I will be amazed. Time after time, though, that is what the service ends up doing to people. The Sainsbury Centre for Mental Health has put the total cost of mental illness to the economy at over £77 billion a year. A figure like that is a salutary reminder that an approach to mental health that adopted a much broader and more imaginative model for assessing cost-effectiveness could well prove highly beneficial. Like the noble Baroness, I think straight away of the proposals put forward by the noble Lord, Lord Layard, who, as she said, has argued persuasively that a substantial investment in talking therapies for those with depression would repay itself in savings of incapacity benefit. I hope that the Government will give that idea the support it deserves and take it forward. That is only one example of the savings that could undoubtedly be made across the piece, if only we were able to deal earlier and better with mental illness and get people who are ill back into employment. Therefore, I hope that the Minister will listen carefully to his noble friend and to the noble Lord who, as I am sure he agrees, know a thing or two about disability matters. They are absolutely right to move our attention away from issues to do with detention and compulsion and on to issues to do with better and more timely service delivery, which are the things that really matter to the vast majority of service users.
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Baroness NeubergerCrossbench- Quote
- I, too, support in principle the amendments of the noble Baroness, Lady Wilkins, and the noble Lord, Lord Williamson. Like the noble Earl, Lord Howe, I am delighted that for a few minutes we have been taken away from issues of compulsion to talk about what mental health services should be like and, indeed, what entitlements patients should have. My noble friend Lord Carlile was right to say that we should be thinking of a very basic Bill of Rights, as it were, for patients who use mental health services. We should be thinking about a right to assessment, support and treatment. The noble Baroness, Lady Murphy, was right to remind us of the work of Marjorie Wallace of Sane, and, indeed, of the work of other organisations, but particularly that of Marjorie Wallace, who has reminded us time and again of people who have told her organisation that they could not get anywhere. Neither individual patients nor their families or carers who have asked for help can get a response from the services. We need to look at what the services are doing. I speak from experience. I am sure that the noble Baronesses, Lady Meacher and Lady Murphy, have had the same experience as I have of the mental health services. I refer to chairing a mental health service trust in central London. The reason that on the whole people get such a poor response is that bed occupancy is so high that the services are struggling to provide for people who are compulsorily detained. Trials, experiments or, indeed, the introduction of a new service such as assertive outreach, which the noble Baroness, Lady Murphy, mentioned, have shown that it is possible to get bed occupancy down in the compulsory services by going for assessment, support and treatment but not necessarily for compulsion. You can make the services much more responsive. There is a lesson for us to learn from that. That is why the insistence on assessment, particularly in the amendments of the noble Lord, Lord Williamson, and the noble Baroness, Lady Meacher, is so important. When assertive outreach was piloted in three London trusts I was still chief executive of the King’s Fund. We piloted the measure jointly with the Sainsbury Centre for Mental Health in three areas with Department of Health funding. I believe that the Minister was party to that on the first occasion that he held his present ministerial office. The pilot was so dramatically successful that assertive outreach was put into the national service framework before the assessment and evaluation of that project were fully completed. That is unusual but I think that it tells you that there is another way of doing things. During these two days of debate we have said time and again that there are ways of thinking differently and of encouraging people to use services. We should not drive them away by the threat of compulsion but allow them to engage with services and feel that they are being offered fair assessment, support and treatment. I say to those Members of the Committee who are not aware how it works that assertive outreach is a rather imaginative process. Often it involves doing a deal with patients. Patients agree to take their medication, having had a full assessment. They engage with the treatment and are compliant. In exchange they often get the support that they have asked for, which on the whole our services are very poor at providing. Sometimes patients get access to housing. Often they say that they want access to employment. We rarely manage that but often we manage to secure daytime occupation. The evidence thus far suggests that such patients have a better quality of life. That experience, in so far as we have had it—it is now in the NSF—should indicate to us by practical example that going for assessment, support and treatment is a better way in than a system that is based on compulsion. I hope that the Minister will take that very seriously because it seems to me that we could reduce the need for compulsion if we were serious about assessment, support and treatment. If we went down this path, we would follow the recommendations of the Joint Committee on the 2004 Bill. We would accord with the Government’s own national service framework—a framework which is at the moment somewhat in danger because the services themselves are having money stripped out of them. Mental health services are losing money to the acute sector due to deficits. That should give us real cause for concern when what we want to see is a system that encourages assessment and voluntary treatment. Other Members of the Committee have said that Rethink’s evidence that 50 per cent of people who are treated compulsorily asked for help but did not get it is a disgrace. It is indeed a disgrace but we also need to recognise that when people ask for and receive treatment voluntarily, the evidence shows that it tends to be much more successful. The Healthcare Commission has told us that some 51 per cent of mental health service users have no access to crisis care out of hours. Yet, if you want a system of assessment, support and treatment that people will engage with voluntarily, you have to have access to crisis care. That fits with the model that the national service framework has given us. The noble Baroness, Lady Meacher, talked at length about the cost of mental illness and particularly of depression. About 40 per cent of people in receipt of incapacity benefit have a mental health problem. The economic costs are huge. I shall not go through all that but we have developed very good ways of supporting people with an alternative to care in an acute ward under compulsion. I refer to the Drayton Park alternative to in-patient care for women and the American idea, which we hope to establish in Britain, of the Times Square hotel of supported housing. Those measures have almost always been funded under charitable or short-term project funding. My noble friend Lord Carlile is right to say that mental health services are still the Cinderella services of our health service. Often but not always you can easily raise money for hospices. You can raise money for cancer and multiple sclerosis. However, it is incredibly difficult to raise money for mental health services. This is an area where we should give patients rights, which need to be backed up with money. Money should not be stripped out of the system. The Government will loathe our saying that this will cost. It will cost in the early stages although in the longer term it may save money. Many of us would argue that it would save money in the longer term. We should have a charter of rights that gives people the right to assessment, support and treatment. That will need funding but not from the compulsory side of the sector. I should like to see this Government have a Bill of Rights that takes on board the principles behind the two amendments that we are debating and which is not just lip service to patients’ rights but shows that we really mean it.
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- Lord Hunt of Kings HeathLabour
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- This has been a good debate. I say right at the beginning that I have no disagreement whatever with how noble Lords have expressed their comments about the need to develop services. It seems to me that the one thing on which the House is united in our debates on mental health is our belief in the importance of mental health services and our wish to strengthen them. We wish, as noble Lords have suggested, to have early intervention and to see that the tragedy of the million people with mental health problems who are on incapacity benefit is put to an end. We are all united in wishing to see that happen. I rather wish that noble Lords might have given the Government a little credit for some of the developments in the last few years. The noble Baroness, Lady Neuberger, by pointing to crisis intervention teams and so on, has illustrated some of the improvements. The noble Earl, Lord Howe, put his finger on the real question: is this amendment the right way of fulfilling our desire to improve services, access, rights and so on? That is the point on which I disagree with noble Lords. I disagree for two reasons. First, the public’s rights on assessment and service provision are already covered in general legislation. Secondly, while I know that noble Lords here tonight would wish to prioritise mental health services above all other services—for I suspect that that is the implication of what they are saying—we also have to look at the impact of identifying simply mental health services and putting strict duties on to local providers, when similar duties will not be placed—
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- Baroness MeacherCrossbench
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- We were only asking for equal treatment of mental health alongside physical disability. I do not think any of us indicated that we wanted a greater priority for mental health.
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- Lord Hunt of Kings HeathLabour
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- I fully understand that. What I am trying to say is that such an amendment to the Bill would, by its very nature, have the effect of forcing the health service and local government to give absolute priority to those services. There would be no similar duty in other areas of the health service. That is my point. I shall mention the legislation that we believe covers the responsibilities. Under the National Health Service and Community Care Act 1990, it is already the case that a person who appears to a local authority to be in need of care services is to receive an assessment of that need. The Secretary of State already has a duty, in the National Health Service Act 1977, to promote a comprehensive health service designed to secure improvement in the physical and mental health of people and in the prevention and diagnosis of illness. There are similar provisions in relation to Wales. Those are significant and important duties. Moreover, a process of inspection and regulation has also been established. We have the Commission for Social Care Inspection and the Healthcare Commission. Wherever the needs of a person being assessed for community care services are such that an assessment is also required from a health professional, the local authority is required to request a contribution to their assessment from the appropriate NHS body and to take into account the health services that are to be provided as a result. There is a statutory responsibility for NHS and local authority bodies to co-operate. Under the existing arrangements, community care assessments already provide the elements that make up the definition of “treatment and support” in subsection (10) of the amendment in the name of the noble Baroness, Lady Wilkins. That is current good practice. Therefore, the legislation itself meets many of the objectives which noble Lords wish to see in generic provisions that apply to health and community care generally.
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- Baroness NeubergerCrossbench
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- I am so sorry to interrupt the Minister, but when he says that the Government will do everything they can to continue the improvements in the mental health services, does that include the money currently being removed from mental health services to plug gaps in acute services?
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- Lord Hunt of Kings HeathLabour
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- A great many switches in resources are taking place. To single out mental health and to suggest that all the money is being taken from mental health services is, if I may say so, a rather gross exaggeration. The health service clearly has to live within its means. That is why we are requiring it not to be in deficit at the end of this financial year. It involves some difficult decisions that affect not just mental health services but others as well. I invite the noble Baroness to accept that we are in the middle of the largest increase in NHS funding in our lifetime and that mental health services have benefited as a result.
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- Baroness WilkinsLabour
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- I am most grateful to all noble Lords who have taken part in the debate and given their support to both the Rolls-Royce and the Mini of these two amendments. I am obviously disappointed by the Minister’s response. The extension of compulsion that the Bill will enact will, as the Royal College of Psychiatrists has pointed out, further diminish the resources that go into mental health care services and make the need for a charter of rights even more important, as the noble Lord, Lord Carlile, pointed out. This is one opportunity in a generation. I would like to reflect on the debate. For the moment, I beg leave to withdraw the amendment. Amendment, by leave, withdrawn.
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- Lord Hunt of Kings HeathLabour
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- I beg to move that the House do now resume and that the Committee stage begin again not before 8.20 pm. Moved accordingly, and, on Question, Motion agreed to. House resumed.
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