Question for Short Debate
My Lords, I know that the Minister is now almost a veteran in your Lordships’ House, but he is new to me and I have not had the opportunity to welcome him to his position, which is one that I held in the past. I hope that he will enjoy his job as much as I did, and I know that, like me, he will probably by now know his place in your Lordships’ House, given its huge expertise on health matters. If he knows that, he will almost certainly succeed in his position.
Earlier this month, the Care Quality Commission produced Right Here, Right Now, an investigation into people’s experience of help, care and support as a result of a mental health crisis. In your Lordships’ House, we fought for, and won, the battle for parity of esteem. Indeed, I am very pleased to say that it was Labour votes in the House of Lords that ensured that the Government wrote parity of esteem between mental health and physical health into law. However, I am afraid that since then it has become clear that the reality does not match the rhetoric. Despite the Government saying that they would protect front-line services, on the coalition Government’s watch the budget for child and adolescent mental health was reduced year on year, and we have seen key prevention and early intervention services stripped back, such as child and adolescent mental health services—CAMHS—and early intervention in psychosis services.
This latest report found that people’s experience of mental health crisis care was simply not good enough, with children and young people in particular experiencing very poor care. I commend the CQC for this report, which clearly shows significant variations in the help, care and support available to people in crisis, and that often a person’s experience depends not only on where they live but on what part of the system they come into contact with. The CQC asked people to share their experiences, and what people told it demonstrates a real weakness in mainstream mental health provision as regards 24-hour crisis care. In some cases, the only recourse for people trying to access crisis services is to a phone line telling them to go to their local emergency department.
For children and young people, the problems are even more acute. There is a lack of health-based places of safety for children and young people. Many units do not accept children under 16, there is the problem of places of safety being already occupied, and there is a lack of CAMHS availability to support out-of-hours care. These issues often mean that children end up travelling many miles away from home. In June 2014, the Royal College of Psychiatrists conducted a survey that revealed that 83% of those surveyed had experienced difficulty at least once in finding an appropriate bed for children and young people, and that 22% of respondents who worked in child and adolescent mental health services had placed a child 200 miles away from their family.
Right Here, Right Now reveals a disparity between adult and child crisis care, particularly in accident and emergency. It found that:
“Through our local area inspections on people presenting to A&E in crisis, we found that there were clear differences in the quality of care experienced by those under 16 compared to those over 18 years old. The liaison psychiatry service met specifications set out in the RAID model. Adults were seen promptly and there were clear pathways through to community services. People aged 16 or 17 would be seen and assessed by the RAID team with support from CAMHS, while those under 16 were referred directly to the child and adolescent mental health service … This may be an appropriate referral route, but in practice it meant that if a CAMHS referral was made after 12.00 noon, the child would not be seen until the following day or potentially after the weekend, as the CAMHS team did not offer out-of-hours service”.
The disparity in care at accident and emergency is particularly concerning given that the number of children under 18 attending accident and emergency for psychiatric conditions increased by 82.5% between 2010-11 and 2013-14.
Young Minds, an organisation that does excellent work, believes that as well as improving the response to children attending accident and emergency with mental health crises, much more should be done to provide early intervention support so that children do not end up in a crisis in the first place. A freedom of information request by Young Minds found that 74 out of 96—77%— of NHS clinical commissioning groups froze or cut their CAMHS budgets between 2013-14 and 2014-15. It also found that 59 out of 98—60%—of local authorities in England have cut or frozen their child and adult mental health services budgets since 2010-11, and that 56 out of 101—55%—of local authorities that supplied data have cut, frozen or increased below inflation their budgets in this area. It has also been revealed that 80 educational psychologist posts have been lost since 2010.
As well as the disparity between experiences of attending accident and emergency, there is a disparity between adults and children when it comes to health-based places of safety under the Mental Health Act. While I am sure that everybody would welcome the move to end the practice of detaining children and young people in police cells, Right Here, Right Now says:
“The decrease in the use of police custody may not mean that people are more likely to be detained under section 136 in dedicated places of safety based in mental health services. It may be that a desire to avoid using police custody has moved the pressure to elsewhere in the local system”.
It also says:
“We also had concerns about the provision of appropriate places of safety for children and younger people. We found that too many providers had policies that excluded young people from all their places of safety … These restrictions created untenable situations where people under 18 were one and a half times more likely to end up in police custody. However, there has been a major drive to reduce the number of children and young people in police custody”,
which we welcome. It goes on to say:
“Between 2012/13 and 2013/14, the percentage of under 18s detained in police custody fell from approximately 45% to around 31% ... This is a positive achievement, but it still means that nearly one in three people under 18 ended up in police custody rather than somewhere they could receive appropriate treatment”.
I have some questions for the Minister. Future in Mind, the report of the Children and Young People’s Mental Health and Wellbeing Taskforce, states:
“If you have a crisis, you should get extra help straightaway, whatever time of day or night it is. You should be in a safe place where a team will work with you to figure out what needs to happen next to help you in the best possible way”.
For many children and young people, as the CQC report makes clear, this is simply not the case. What steps is the Department of Health taking to implement Future in Mind? Indeed, what are the Government doing to ensure that early intervention actually happens? How will they persuade the CCGs to give this the priority that it needs, as this is the obvious and oft repeated answer to how to mitigate these crises? Given the paucity of child-appropriate health-based places of safety, as the CQC highlights, does the Minister share the CQC’s concern that the banning of police cells, while most welcome, will create pressure in other parts of the system? Does the department have any solutions?
In Stamp Out Stigma, the Time to Change campaign seeks to tackle the stigma surrounding mental health and to break the taboo that is often associated with mental health problems. I was recently surprised to read the comments made by a Member of this House about mental health, which illustrates why we need to be on our guard not to perpetuate, even by accident, the stigma that goes with mental health issues. In a discussion about lowering the voting age, a noble Lord said:
“My Lords, does the Minister agree that an important part of due diligence in the policy of lowering the voting age would be to consult child development experts? Is she interested to learn that the view of a child development expert who has treated 16 and 17 year-olds for depression, eating disorders and other health issues over many years is that while quite a few 16 and 17 year-olds would be old enough to make a good decision in this area, many would not?”.—[Official Report, 1/6/15; col. 157.]
Several arguments can be made about not lowering the voting age. The issue of mental health is not one of them. In fact, it is probably a rather dangerous road down which to tread.
I have a final question for the Minister. Labour committed to enshrining in the constitution a right to mental health therapies. Just before the election, the Conservatives announced that they would do the same. The Government have launched a consultation, which has subsequently concluded. When can we see a response to that, and what action might be taken?
Right Here, Right Now highlights yet again that mental health services are failing and that this is a very unsatisfactory situation that creates terrible distress, stress and heart break, and sometimes even worse, for people with mental health problems and their families.
My Lords, I thank the noble Baroness, Lady Thornton, for introducing this debate. I was delighted that she and her colleagues felt able to support the Liberal Democrat amendment on parity of esteem. The noble Baroness has given a very comprehensive outline of the problems highlighted by the report and I will not repeat them. Suffice it to say that we on these Benches will support anything the Government do to alleviate the problems of young people with mental health issues before and during crisis situations. Early access to treatment is the key to reducing the number of crisis occurrences and good planning of adequate services and information to patients are key to making sure that people in crisis can get the help, as the CQC says, “right here, right now”.
We are proud of the record of our Liberal Democrat Ministers, Paul Burstow and Norman Lamb, in the last Government. They were involved in announcing: parity of esteem for physical and mental health; an increase in funding for mental health, including more in-patient beds; increased focus on child and adolescent mental health; and equal waiting time targets. The Children and Young People’s Mental Health Taskforce report Future in Mind is an excellent blueprint for the five-year national programme of improvement commenced under the auspices of my right honourable friend Norman Lamb and it is part of his excellent legacy in the Department of Health. The mental health crisis care concordat was another great achievement and it is good to know that everyone has now signed up to it and that most local authorities have a plan to deliver it. However, resources have been scarce for most of the past five years so this progress has to be seen in the context of an earlier reduction in the number of mental health beds and years of insufficient focus on children and young people.
I welcome the Government’s proposal to ban the use of police cells for young people in crisis. However, I want to talk about timing. There are times when Governments, in their rush to do the right thing, forget that if they do not put other things in place before acting, they can make things worse. I can think of the spare room subsidy which the previous Government imposed without ensuring that sufficient smaller properties were available for people to downsize. That is why my party put forward a Private Member’s Bill to ensure that tenants would not have to contribute for spare rooms unless they had been offered suitable smaller accommodation and refused it. Sadly, that was defeated in another place. Another potential example is the current Government's plan for seven-day availability of GP services at a time when we have not even got enough GPs to fulfil current demand.
I am concerned that if the ban on use of police cells is brought in before the problems highlighted in this thematic report from the CQC are addressed, we will be leaving young people in crisis with nowhere to go. I do not want to see police officers disciplined for bringing young people into police stations when there are no age-appropriate therapeutic services available for them and that is the only thing they can do. I do not want to see A&E departments trying to cope with these young people, who need time that the staff do not have and a calm atmosphere—which is not going to be found in A&E. I do not want to see young people failing to call for help when they need it because they know that the police cannot protect them—often from themselves—and neither can A&E.
It really does not seem right that people are being turned away from services when they ask for help only to be detained when their condition deteriorates. However, although they are not the appropriate service to help in mental health crises, it has to be said that the police do their best, and many patients in this situation report that they get better help from them than from some other services. Some forces have implemented rather creative strategies. I have heard of at least one force where officers called out after hours to a person who clearly is having a mental health crisis take a community psychiatric nurse with them. These nurses are able to assess the situation and calm the patient, allowing him to be dealt with appropriately. This is an excellent example of thinking outside the box and is to be commended.
I ask the Government to ensure that before this very welcome ban comes into force they have all their ducks in a row, so to speak. My question, therefore, is: how will the Government assess when this is the case so that the ban can be safely implemented once the legislation has gone through?
There is one large group that is particularly at risk in these situations: young people who have recently left care, many of whom develop mental health issues soon after having to live independently. Many of these young people do not have a responsible adult to turn to and do not access services early, and far too many of them suffer a crisis and harm themselves or even commit suicide.
There is evidence that the problems overall may be understated by the official figures. Although only 53 under-15s and 312 16 to 17 year-olds were admitted to adult mental health wards in 2013-14, people were counted only once no matter how many times they were admitted in the year. These figures come from an Answer to a Written Question from Luciana Berger.
Another problem is poor anticipation of a future crisis and poor communication between services. The report we are discussing found that the rate of people admitted to acute hospital via A&E for a mental health condition varied across the country. In 2012-13, more than 4,000 people had attended A&E multiple times—on average, at least once a month—in the five years before being admitted. This is likely to be a sign that local services are not working well together and that people are not getting the specialist help they need. Should there not be guidelines that a red flag is raised when these multiple attendances occur?
Given that the pathways into help in a crisis are several, can the Minister reassure us that local concordat teams are covering all the bases, ensuring good communication and providing services at the right time? Will he emphasise that patients need to know who to call to get help? One of the worst findings in the report was the large number of patients at risk of a crisis who said that they did not know who to call in an emergency—no wonder they land up in A&E.
I realise that the task for local commissioners is a difficult one. They need to predict what crisis services will be needed and at what times, and make those services available. This requires a deep knowledge of the status of patients in their area and a commitment to providing therapies which will prevent problems reaching crisis point. So my final question is: how are the Government assessing how well this is being done?
My Lords, I thank my noble friend Lady Thornton for introducing this debate. She has highlighted many of the problems facing young people that are set out in the Care Quality Commission report, as has the noble Baroness, Lady Walmsley. Both have said that young people are particularly vulnerable and badly served.
As we can see from the excellent Library briefing, there have been numerous deliberations about young people’s mental health from a variety of sources. Importantly, the then Minister, Norman Lamb, said earlier this year that these set out a compelling economic case for change, and change is what we have to focus on. The All-Party Group for Children, which I chair, has conducted an inquiry into the development of good mental health and emotional well-being for young people in the face of life’s challenges. I shall say a little bit about that but will first ask the Minister: what is happening to all the initiatives for young people and reports that have come out in recent years?
I want to mention briefly the report published by the Association for Young People’s Health, based on key data on adolescence. The report points out that half of all cases of psychiatric disorder start by the age of 14, and three-quarters by 24. Around 13% of boys and 10% of girls have mental health problems. The most common issue for boys is conduct; for girls it is emotional difficulties. Mental health issues include eating disorders, attention deficit and hyperactivity disorder, behavioural problems, self-harm and, in extremis, suicide. Mental ill-health is on a spectrum from low-level to severe. It is not necessarily an extreme psychiatric disorder. Good mental health can be encouraged, and I shall say something about this in a moment.
As I turn to the findings of the all-party group inquiry on children’s mental health, I thank yet again the National Children’s Bureau for its wonderful support, not only in organising the evidence sessions but in recording the findings, and for supporting children in general. The inquiry on mental health was a joint one, involving other all-party groups: those on child protection, penal affairs, and looked-after children and care leavers. We looked at three key challenges: relationships, service provision and transitions. We took evidence from young people, doctors, charities, schools and researchers.
One thing which became very clear at the beginning was that emotional exploitation online has a devastating effect on children. There is good evidence on this from ChildLine. Parents are often baffled by the online world and need advice and help. There is the need for better and more easily accessible support for young people, including online services such as cybermentors and online counselling. Is the law keeping up with technology? Will the Government encourage such services and the provision of extra information for parents?
The manager of a secure children’s home told the inquiry that there need to be expert child-centred holistic services to meet the complex needs of young people, including appropriate assessment of health, substance misuse and offending behaviour. Interventions need to include therapy and counselling, such as art therapy. Also important for young people is access to employment and accommodation.
I now want to look at what might be done to help prevent distress in children in the first place. A supportive family is all-important. Sadly some children do not have this and, even when they do, things can go wrong. Early spotting of learning problems such as dyslexia, and of behavioural problems such as bullying or self-harm, is essential. This may happen through a number of agencies, including parents, the voluntary sector, schools, children’s services, or the police. The old issue of services being co-ordinated and accessible is important, and we sometimes miss out on problems and the potential for early intervention. Others have asked this question, which I will repeat: how can we improve cross-agency working?
I will say a word about schools. The all-party group heard from pupils, teachers and researchers about how school can be distressing for some children. Focusing on performance and academic success can be unproductive if emotional needs are not met. It was said that student well-being is as important as academic achievement and must be integrated into every part of school life and learning. Children can develop self-esteem and resilience through a school’s approach. I have long supported, as has the noble Baroness, Lady Walmsley, the inclusion of statutory personal, social and health education in and outside the school curriculum. I am aware that the Government are considering the call of the Select Committee on PSHE to make it statutory in schools. I hope that the Government will take a positive approach to that.
An earlier inquiry by the All-Party Group for Children calls for action to implement the recommendation of the Children and Young People’s Health Outcomes Forum. It states that the Government should make it a legal obligation for public bodies to have due regard for children’s rights and that schools should ensure they develop a full programme for personal development, as well as academic skills, and link to support services. A cross-government youth strategy should be established, building on the report Positive for Youth. I hope that the Minister will be able to reassure the House that proactive measures, such as those I have mentioned briefly today, will be made concrete so that we can support children and families in preventing mental health problems and offering support and services if they arise.
My Lords, it is a pleasure and a privilege to take part in any debate in this House but I am very grateful to have put my name down to make a small contribution in this Short Debate. The House demonstrates the quality of its service to the nation when people are able to stand up from their own experiences and ideas to stimulate the Government and others into thinking again about how things are done. I begin, as I have many times before, by thanking the staff of the Library for producing such an excellent document to give us a guide. It is not the first time and they never let us down, so I am very grateful. The trouble is that it is like going into a self-service just for a snack. By the time you have decided to be serious, you have read all the briefing—and I did read it all—so you realise that you rely upon other people to give you a nudge and a guide.
It is at least 80 years since I could say that I was a young person of the kind we are talking about. I was 90 about a month ago, so I can reflect on the nature of childhood as it was when I was a child and childhood now. Of course, there is no comparison for the bleakness of the ability of your mum and dad to provide you with toys, outings, books or encouragement, as my dad was on the dole for 10 years from 1930 to 1940. I passed my 11-plus but could not go because of my circumstances. Eventually, I got a degree from the Open University—a BA. I got an honorary MA afterwards and then became a member of the Privy Council. We need to recognise that the challenges before young people and their parents in the present years are completely different from the challenges when I was a boy in the 1920s and 1930s.
I congratulate my noble friend Lady Thornton on the comprehensive way in which she introduced the subject. She has a point of view and she has answers to the questions. I do not have many questions and I have no answers to any of them. The Minister will realise, as I do and the House does, that the money available in the budget plays a major part. The problems can be exposed, as they are in this debate. Every person who has spoken has a contribution to make. The idea that there is a solution to every problem is not new. There is a solution but it is a question of priorities with the money available. One thing that strikes me about where we are falling down is that there is a lack of co-ordination among the various services. In other words, this is not a political issue—except on the budget, which we could say something about if it was necessary. It is about co-ordination between the services.
One gets terrible news almost every week of a problem among the police, the press or media, or the schools. In the phrase that came before, what has happened to all the reports? What we are debating is not brand new. There is very little in it that we have not had warning about in the past. We have to try to recognise that, while the heart is in the right place, it is sometimes difficult to exercise what one knows to be needed because there are priorities. I would be happy to speak about my own list of priorities but that is not the point here. The problem that the Minister and his colleagues have is: what can we do with the limited resources that we have? It ever was that the amount of money available at any time is insufficient to do everything that one needs.
I have been very impressed by what I have heard this afternoon. What we need is a Minister who will go away and look at the manner in which people slip between the various services. With all the various agencies that there are, it ought not to be possible to slip between. Yet whenever there is a scandal of some kind, it is revealed that the evidence which could have been acted upon was available but not conveyed to the proper people. One thing that the Minister should take away, in a busy life and with limited capacity as far as money is concerned, is to ask his colleagues to come up with ways in which they can collectively make sure that they look at the needs of young people now. More than ever before, they are at risk.
My Lords, I congratulate the noble Baroness, Lady Thornton, on securing this important debate. Failures in crisis care for children and young people often make for attention-grabbing headlines. We have all heard the stories of children being admitted to hospitals hundreds of miles away from their families, and of children held in police cells. The Care Quality Commission’s Right Here, Right Now report and other findings tell us that these dreadful situations are not isolated incidents but reflect a larger failure to provide sufficient crisis care for children and young people.
The adoption of the mental health crisis concordat last year was an enormous step forward for the provision of crisis care, pioneered by my right honourable friend Norman Lamb when a Minister. Central and local government and leaders of key services agreed to work towards making sure that compassionate and understanding crisis care would be available 24/7; that a mental health crisis would be treated with the same urgency as a physical health crisis; that people should be treated with dignity and respect in an environment that is conducive to their needs; and that appropriate follow-up services would be provided. That sounds great, but delivering the promises of the concordat will require more than generalised statements of support, very welcome as they are. We need to ensure that promises made in local area action plans are delivered. It will mean tackling long-standing failures in commissioning, which in turn will require strong and sustained local leadership and, crucially, the necessary resources. As we have already heard today, children and young people tend to receive a lower quality of crisis care. I thought it was shocking that the CAMHS 2013 benchmarking report noted that only 40% of CAMHS had crisis care pathways, as they are called.
What happens to those young people who cannot find the care they so desperately need—the other 60%? It is not a particularly encouraging picture. The CQC report found clear differences in the quality of care for children turning up at A&E in crisis compared to the quality of care for adults. In accordance with the rapid assessment and intervention model, adults are generally seen promptly and directed to community services, while 16 and 17 year-olds are assessed with support from CAMHS and those under 16 are referred directly to CAMHS. Your Lordships might say that sounds absolutely right but, as we have already heard today, the reality is that CAMHS are often not offered out of hours and if a CAMHS referral is made after midday, the child will often not be seen until the following day or even until after the weekend.
On the plus side, I was pleased to note that the Department of Health and NHS England have committed in their publication Achieving Better Access to Mental Health Services by 2020 to develop a national all-age liaison psychiatric service in A&E departments. This is both welcome and timely. Such a service should help ensure that children in crisis receive at least some support immediately. However, it is surely unacceptable that access to referral services should be so delayed. Could the Minister say what plans the Government have to establish an out-of-hours mental health service for children, as the recent Children and Young People’s Mental Health and Wellbeing Taskforce report, Future in Mind, recommended?
What happens if a young person experiencing a mental health crisis needs to be admitted to hospital? The reality is that in hospitals where in-patient treatment is provided, there are simply not sufficient places for children and young people. Although the prevalence of mental health problems has been increasing, there was a 39% drop between 1998 and 2012 in the number of mental health beds available in England, and this shortage has particularly impacted on children. In a recent survey by the Royal College of Psychiatrists of its trainees, 83% said they had difficulty finding an appropriate bed for children and young people, compared to 70% who had difficulty finding an appropriate bed for an adult. As a consequence, many children end up being admitted to wards for adults or to hospitals far from home. Of those surveyed, 22% reported having to place a child 200 miles away from home—a fact I find truly shocking. What chance does a young person have to recover without the care and support of their family nearby? Could the Minister say what assessment the Government have made of whether there are sufficient beds to ensure that children with severe mental health needs are able to access appropriate in-patient care in their area?
The availability of effective home treatment teams for children and young people can reduce the number of people who end up at A&E or who have to be admitted to hospital, which of course must be desirable. It is encouraging that the task force’s report referred to earlier, Future in Mind, found some good examples around the country of dedicated home treatment teams for children and young people. Could the Minister say what steps are being taken to develop improved information about the provision of these services and, indeed, to expand their provision?
Since the concordat, there has been widespread agreement about the need to stop the practice of holding children and young people in police cells as a so-called place of safety. I was pleased to see a specific commitment in the gracious Speech to legislate to ban this practice. This approach is already starting to make a difference, with numbers starting to fall. However, it remains the case that one-third of children and young people detained under Section 136 are held in police custody. Political commitment and the proposed change in the law, although very welcome, will not be enough. The truth is that the excessive use of police cells as places of safety is largely the consequence of operational and commissioning failures—a key theme running through my remarks today.
Too often, police stations are used as places of safety because health-based places of safety do not accept children. The CQC report found that 35% of the health- based places of safety surveyed do not accept under-16s. Similarly, research from the Howard League estimated that 74% of mental health trusts do not provide a specialised place of safety for children. I warmly welcome the Government’s announcement that they will commit £15 million to deliver health-based places of safety. What steps will be taken to ensure that clinical commissioning groups prioritise investment in this crisis care provision, particularly for children and young people?
To conclude, when people experiencing mental health crises do not have access to the sort of timely, effective and compassionate care that people with physical health problems do, it is not just unfortunate, it is simply unfair. It is even more unfair when children and young people experiencing a crisis relating to mental health problems do not even have access to the level of care that adults do. We can and must do better.
My Lords, I very much welcome the debate and very much support the speech made by my noble friend Lady Thornton. I also welcome the work done by the CQC, which identified some good practice but also raised some very serious failings in services. My noble friends Lady Massey, Lord Graham and Lady Thornton have rightly focused on CAMH services and the failures that have been very well documented. We know that the budget for CAMH services has been cut in real terms from £766 million in 2009-10 to £717 million in 2012-13. As we have heard, NHS England’s own 2014 tier 4 CAMHS report confirmed that 16% of patients travelled more then 100 miles to receive treatment, with many going more than 200 miles. It is clear that access for these young people to 24/7 services has worsened, with A&E or a police station often the only place to go.
I have no doubt that the Minister will put his trust in the crisis care concordat. I acknowledge the excellent work that has been done, and the concordat is clear: people experiencing a mental health crisis should have access to the help and support that they need 24 hours a day, seven days a week. But what is the status of the concordat? Is it being performance managed? Who, ultimately, is accountable for its implementation?
The CQC recommends that representatives of local crisis care concordat groups ensure: first, that all ways into crisis care are focused on providing accessible and available support; secondly, that commissioners are to be held to account; and thirdly, that they should engage with partners to encourage innovation. The question is how. If, for instance, their action plans are insufficient, what is going to happen and who is going to make them turn them into effective action plans? The concordat does not specify which organisation should lead this work locally. Why on earth not? The care concordat approach is an excellent one, but it lacks bite because no one is being held accountable for its implementation. Can the Minister sort this out and make sure that someone is truly held accountable?
I read a letter sent very recently by the Minister’s right honourable friend Mr Alistair Burt to the mental health crisis care concordat national signatory organisations. It is a remarkable letter of four pages, reading as eloquently as I would expect because DH officials drafted it. I have told the Minister before that DH officials are very good at writing letters and reports. However, it is all words. There is absolutely nothing in it. It has nothing to say about forcing the pace locally on implementing the concordat.
Of course, the Government have form here. I will not cross swords with the noble Baroness, Lady Walmsley, about credit for the parity of esteem amendment. All I will say is that it might have been her amendment but it was our votes “wot done it”—but we look forward to working together in future. Yet, despite the law, the NHS is determined not to implement it. We start with what can only be described as the outrageous decision of NHS England the year before last to discriminate in mental health funding as opposed to other services.
We have been told that funding for 2014-15 in mental health was planned to rise by £120 million. What was the actual outturn figure? Why do the Government say that more money will go into mental health whereas my understanding is that the forward plans of mental health trusts show that many are planning for a reduction because they have no confidence whatever that clinical commissioning groups will actually do what they were told? NHS England has direct control over CCGs. Why is it not informing CCGs that they must put more money into mental health services?
We now have transformation plans. My understanding is that the Government tasked every CCG with creating transformation plans outlining what they will do to deliver mental health. How will we judge whether those have been successful? We know that mental health data collection is poor. We also understand that the Government are producing guidance for CCGs on how to complete the transformation plans. A key question is: they produce the plan, but then what? Who will actually hold them to account for delivering on it?
That leads me to the better care fund. The Minister knows that this is designed to provide a joint approach to the planning and delivery of health and social care services. Now, given the pressures on A&E, which is really what this is meant to address, and given that we know that because of the cutbacks in mental health services more and more people with mental health issues come to A&E, I would have thought that mental health services would be at the heart of these better care fund plans. However, my understanding from Written Answers to PQs is that of the £5.3 billion of plans submitted in September last year, a mere £370 million was planned for investment in mental health services. That is an extraordinarily low figure. It means that the health service is determined not to implement parity of esteem despite it being a legal requirement. Finally, when will the Government get serious about making the NHS not only respond to guidance or plans but actually act in relation to mental health according to the law of the land?
My Lords, I congratulate the noble Baroness, Lady Thornton, on bringing this really important debate to the House. I also pay tribute to the noble Lord, Lord Graham, for his very perceptive and important contribution. He put his finger on it when he said that co-ordination of services for patients who often have huge and very complex difficulties lies at the heart of all we must do. He also said that although little is new in life, the environment in which young people grow up today is very different from that in which he grew up. Although in many ways the environment has improved, the pressures on young people growing up today are probably greater now than when the noble Lord was a boy. The noble Baroness, Lady Massey, referred to this and I will bring it up again later in my speech.
On 18 May, the Prime Minister underlined in his first major speech following the election that mental health, including the mental health and well-being of young people, is a key priority for this Government. The noble Lord, Lord Hunt, can be assured that the Government will hold CCGs and NHS England strongly to account for delivering the substance of parity of esteem. For too long, parity of esteem has fallen into motherhood and apple pie territory. We need serious resource behind it to ensure that we deliver it on the ground.
Last year, the Department of Health asked the Care Quality Commission to review the experiences of people receiving crisis care. The resulting report, Right Here, Right Now, shows that although there is some excellent practice in areas such as Lambeth there is far too much variation across the country in the quality of crisis care—and, as the noble Baroness, Lady Thornton, noted, between services as well as geography.
The report provided powerful insights into the stigma that too many service users face. One patient from the report said:
“A&E was horrible. I felt like I was being judged for inflicting injuries on myself and that certain staff actively didn’t want to treat me”.
As Dr Paul Lelliott, Deputy Chief Inspector of Hospitals at CQC, who led the review, stated, there is a,
“real weakness in mainstream mental health provision as regards 24 hour crisis care. In some cases, the only recourse for people trying to access crisis services is to a phone line telling them to go to their local emergency department”.
As other noble Lords said, going to an A&E department is, for someone suffering a mental health crisis, no solution of any kind.
Another patient said:
“I have a clinical illness. It’s not my fault my brain chemistry fluctuated … To be treated as a drunk, an inconvenience and with visible contempt only makes it worse”.
That points to a need for greater training in some A&E departments and the importance of having a psychiatric liaison nurse in A&E departments. The report also found that in some areas there are still problems with under-18s being detained in police cells under Section 136 of the Mental Health Act. I agree wholeheartedly with the noble Baroness, Lady Thornton, and others that this practice is wholly unacceptable. I will say more on that a little later.
Dr Lelliott stated that there are reasons to be confident for the future as well. We are beginning to see a shift in public attitudes to mental health, away from the stigma of the past. As the report states, there has been huge progress in improving crisis care, thanks to the crisis care concordat and successful approaches such as street triage.
The crisis care concordat was launched in February 2014 and signed by more than 20 national organisations. It seeks to improve the experience of those in crisis and in particular to prevent those detained under Section 136 of the Mental Health Act being held in police cells. I spoke not all that long ago to a young woman of no more than 17 who had had a mental health crisis and tried to take her own life. She spent two nights in a police cell. It is hard to imagine a worse place for a young woman to spend time. That was two years ago.
All localities signed up to the principles of the concordat before the end of 2014. Detailed action plans are now in place across England and set out how local partners will work together to improve service responses for people in crisis. I have taken on board the words of the noble Lord, Lord Hunt, that we must be able to assure ourselves that effective action is taken on the ground and that there is clear accountability.
Since the launch of the concordat in February 2014, the number of times that people of all ages were detained in police cells under Section 136 has fallen by 55% compared to 2011-12. This marks a considerable achievement in meeting the concordat’s ambition. There was also a very big reduction in the number of under-18s detained in police cells under Section 136 for the first time since figures began to be collected in 2011-12, with 145 cases, an almost 40% fall within the year. But I agree wholeheartedly with the noble Baroness, Lady Thornton, that one case is one too many. There is good progress but more work to be done.
In May, my right honourable friend the Home Secretary announced that the Government will reform the law on use of police cells to end this practice altogether for under-18s. I am pleased that the noble Baroness, Lady Tyler, supports that move. The Government will also clarify the legislation so that, for people of all ages, police cells are used only in very exceptional circumstances. A number of noble Lords and noble Baronesses have made the point that there is no point in stopping people going into police cells if alternative provision is not made elsewhere. The Government have committed £15 million to improve the provision of health-based places of safety, so that there is better availability of alternatives to police cells.
The insights from the Right Here, Right Now report will also directly improve crisis care, influencing the Care Quality Commission’s regime for future inspections. In addition, the Department of Health, NHS England and Mind are supporting all localities to develop and improve their local concordat action plans in light of the CQC’s review.
The noble Baroness, Lady Walmsley, gave an example of police being accompanied by a therapist. The CQC report makes reference to street triage. These are schemes whereby a police officer might be accompanied by a nurse, therapist or someone else, when they meet people going through a crisis. Paul Lelliott particularly marked that in his report as being a very good development. The Department of Health has funded pilots using street triage with nine police forces, and I believe that 25 police authorities are now using that triage as a way in which to make a bad situation at least no worse. There have been some very encouraging results, with the use of Section 136 to take people of all ages into police custody almost eradicated in many of the pilot areas.
Liaison and diversion services are also being used to help children, young people and adults in crisis. They identify, assess and refer people with a wide range of mental health, learning disability and substance misuse vulnerabilities when they first come into contact with the youth and adult criminal justice systems. NHS England has now rolled out a national liaison and diversion standard service specification and operating model serving 50% of the English population, and it is anticipated that that will cover the whole population by 2017-18.
It is clear that we need to do more to ensure that, for those in need, help can be found in the right places at the right time. The noble Baroness, Lady Tyler, made the very strong point that it must be unacceptable that some young people have to travel more than 200 miles to find an appropriate bed. The previous Government supported NHS England with £7 million to provide additional mental health beds for children and young people. This increased the number of beds to more than 1,400, the highest this has ever been. But I agree completely with the noble Baroness, Lady Massey, that, while we must ensure that help can be found for those in crisis when it is needed, it is not enough simply to provide more and more beds. Home treatment is also very important.
Three-quarters of mental health problems in adult life begin in childhood. It is therefore essential that we focus on improving the whole care pathway for children and young people’s mental health, preventing issues arising, and taking action before hospital treatment is required. I can confirm there will be an additional £1.25 billion over the next five years to enable transformation across health, social care and education for children’s mental health and well-being. In addition, we are investing £150 million over the next five years in services for young people with eating disorders and those who self-harm. Although this Government can take credit for that, I pay tribute to the Liberal Democrats, and particularly Norman Lamb, for ensuring that mental health was so high up the agenda.
I take the strictures of the noble Lord, Lord Hunt, when he says that we must have clear accountability for spending that money. I place considerable hope in the report that has been commissioned by NHS England from Paul Farmer, the chief executive of Mind.
I have been told that I have only one minute left. That is the difficulty with debates in the House of Lords: all the comments are so helpful that it is hard to do them all justice. I conclude by saying that we have all talked about parity of esteem, in this and the other House, for too long. Until now it has been just motherhood and apple pie. I hope that the resources that we are putting into mental health and the accountability that needs to back them up will make a reality of that expression. I pay tribute to Paul Lelliott of the CQC for his very valuable report and thank the noble Baroness once again for bringing the debate to the House.