Question for Short Debate
My Lords, first, I thank all noble Lords who have indicated their wish to speak in this debate. They are all Members of your Lordships’ House who have a considerable interest in this area. Perhaps I may mention in particular the noble Baroness, Lady Hollins, who, as a colleague in the Royal College of Psychiatrists, was probably more responsible than anyone for including the notion of parity of esteem in the Health and Social Care Act 2012. That is one reason that we are debating this Question this evening.
I also wish to mention the noble Lord, Lord Lansley, who was of course Health Secretary. He recently put his name to a letter, along with every other Health Secretary in this country over the last 20 years and a number of other senior concerned people, to talk about how the failure to provide appropriately and fully for mental health is a stain on our nation. I look forward to the debate because I think that it provides another opportunity for us to keep this important matter to the fore—not just mental health but the question of how we address these issues.
I should start by declaring two interests. First, I am a fellow of the Royal College of Psychiatrists and a clinical professor at the University of Maryland in the United States. Secondly, I was one of the people who negotiated the Belfast agreement. The first of those may seem fairly obvious and the second a little more opaque, but the reason for mentioning it is that the notion of parity of esteem was central to the Belfast agreement, long before it was discussed in terms of mental and physical health.
It is important because there were two approaches to the notion of parity of esteem there. The first was that parity of esteem really meant equality of treatment between Protestants and Catholics—between unionists and nationalists. The other, to which I adhere, was that parity of esteem was about an approach to all the people in the community. It was not about a dividing up into one side and the other and a balancing up, but about parity of esteem for all elements of the community—those who came originally from Ireland, those who came in later and those who have come more recently. Parity was not a question of one side and the other.
That is relevant to this debate because it seems to me that there is a danger that we see addressing these issues as a balancing-up of the funding, structures and championing of mental health against those of physical health. There is no doubt that there is certainly a case for that, and I have no doubt that other noble Lords will speak to the facts and figures and explain that mental health has always—certainly in living memory—been the Cinderella of health and social care, and how despite commitments in law and political policy, there is not much evidence that the situation is dramatically improving. That being the case, of course it is appropriate for us to press for things to improve, and to try to ensure that funding and structures do not disadvantage the care of the mentally ill. However, at the same time, we need to ask ourselves some questions. I would argue that instead of repeatedly returning to the issue of changing structures—and the Health and Social Care Act became much more famous for changing structures than it did for the inclusion of the notion of parity of esteem—engineering the cultural change emblemised by the notion of parity of esteem could fundamentally be much more important. That is what I wish to address, and other noble Lords will pick up on the other issues.
When Thomas Jefferson penned the American constitution, he described the inalienable rights as life, liberty and the pursuit of happiness. If any politician nowadays was to propose the pursuit of happiness or a ministry of happiness, they would probably be made fun of. That is partly because words change their significance and meaning, and the words of the 18th century do not necessarily fit with the language of today. Rather than “the pursuit of happiness”, the language that we might use is “the development of mental, physical and social well-being for our people”.
The notion that the pursuit of happiness, or of mental, physical and social well-being, might be a new ambition for health was picked up by the former Minister of State Paul Burstow, my friend and colleague, in a CentreForum panel and publication, which the noble Lord, Lord Adebowale, also participated in. It said that the future perhaps is not in creating structures in which mental health gets a fair crack of the whip or slice of the cake, even though that is extremely important, but rather that we try to look at addressing the well-being of individuals and communities in our country. In truth, no matter how much we deal with physical health problems, if people do not feel a sense of well-being, no amount of physical health will make life worth while.
I remember as a very young psychiatrist in Northern Ireland trying to get across on the radio and television issues about depression and bereavement and so on. I was joined by a very senior emeritus professor of surgery, Professor Rogers. I thought, “Oh my goodness, this is extremely intimidating; what is he going to say?”. I made my little presentation and he said, “I want people to listen to this because in a lifetime of working in surgery, with all the horrible diseases and disorders that people have, I have seen very few of them who actually wanted to take their own life. It is a measure of the deeper distress of many people when they are mentally ill that they sometimes feel a need to put an end to their life and their misery”. I have never forgotten that. We all try to promote our own causes, and yet here he was saying, “Yes, I did all sorts of work; but fundamentally, if people get to the point where life is not worth living and they take their own life, it is an incredible marker”.
In 2010, I did a report for the Royal College of Psychiatrists on self-harm and suicide. We marked out a number of things that needed to be done to address the increasing level of suicide. It is not getting better. Arguments might be made about facts and figures, percentages of money, numbers of people being seen, numbers of out-patient appointments and access to services. All of those are relevant and necessary for those who are trying to commission and provide services. But if we all know in our hearts that people who contemplate taking their lives have obviously reached a point that nobody should find themselves reaching—there has certainly been inadequate help and support—that marker tells us that something important has failed in addressing the well-being of our people.
This is also not really a party-political thing, because it has always been a matter of concern on all sides of the House. The noble Lord, Lord Prior, wrote me a note to apologise for not being able to be here for the debate, but he knew that he would be well represented. He said that this was a matter of great importance. Let us not treat it as a question of party politics. Let us try to understand what we need to do to make a real change. In the CentreForum document and the recent report by the King’s Fund and others, there has increasingly been an appreciation that we need not just to build on the pillars of individual kinds of illness and care but to find a way of bringing them together.
At home in Northern Ireland, we ended up with an integrated health and social care system. That was the one that I worked in all my life. The political problems meant that social care and health care—mental and physical—were all taken together and were able to be dealt with without arguing about budgets, where services were or any of those kinds of things. It helped. There is no doubt that it helped. However, it is not just about an integration of structures. It is also about a cultural change that helps us understand that mental health is not about one bit of us, physical health about another bit of us and social well-being and our relationships about yet another bit of us. We cannot be divided up in that way in any helpful fashion. It is about dealing with each other as human beings—all of us, the whole package of being a human being.
One of the tragic and disastrous consequences of what is happening in politics now globally is that people are not treating others as human beings. We can do all sorts of horrible things to people when we do not treat them as human beings. We need to think about things in terms of mental and physical health care. Of course we need to have specialists to focus on this particular aspect of the problem or that particular disorder, but there is no part of our physical care that does not have a mental and emotional component to it. There is no part of our mental life that is not related to our body. There is no part of our existence that is not about relationships with other people.
My question for the Minister is not just about what is being done to promote parity of esteem in terms of funding and making sure that it is fair funding. I am not arguing about the equality, but is it fair or is it not? Is it becoming less fair and if so can we do something about it? Yes, of course there are issues about structures and questions of commissioning, but are there things that we can do to change the culture and approach that ensures that we are dealing with the well-being of the people who live in our communities and of the communities themselves? That kind of cultural change is necessary if we are to achieve what we want to achieve in terms of parity of esteem for these different components of ourselves and our fellow human beings. I am keen to know what the Government feel able to do to promote that.
My Lords, I congratulate the noble Lord, Lord Alderdice, on securing this short debate and on the way he introduced it. He set a very helpful frame for it. It is fundamentally not just about funding and structures, but about culture and attitudes. That is what we are aiming for, although I confess that, not for the first time, I will need to talk about funding and structures as well. Perhaps they are entirely complementary.
The noble Lord was kind enough to refer to back to 2011 and the inclusion in the Health and Social Care Act of language intended to demonstrate the commitment to providing health care services to tackle both physical and mental illness. Of course, it was not the first time that public policy had set that objective. It was simply intended to reinforce the February 2011 strategy document, No Health Without Mental Health, published by myself and Paul Burstow, who, as the noble Lord Alderdice, has just said, has been his colleague and was mine at the time. I pay tribute to his work on the document and indeed on the Care Act 2014 which was passed subsequently.
The point about No Health Without Mental Health is precisely the point made by the noble Lord in his introduction to this debate: we completely mislead ourselves if we see physical health and mental health as occupying in any sense different places for us as individuals and us as a society. We cannot have one without the other. In truth, I suspect that if we want to make the greatest possible progress in improving the health of the nation overall, it is in improving mental health that we can secure the best potential return. For young people suffering from serious mental health problems, the impact on their lifetime health and life chances is dramatic. The premature mortality of those with severe mental illnesses is clear, and this is probably the group in society on whom we could make the greatest impact if we could reach out and treat them successfully at an earlier stage. People are not dying because of their mental illnesses; they are dying because of the range of physical illnesses and lack of physical health which are the concomitants of their severe mental illness.
That is why No Health Without Mental Health was the title chosen for the document. Because of that thought, the strategy set itself the objective of trying, as we put it, to “mainstream” mental health into the NHS. It is a fact of NHS life since its establishment in the 1940s that mental health has always been regarded as something separate and different, but frankly it is not. It is a single part of the picture of how we deliver NHS services. Our objective, as part of the structural process, was to try to engineer mental health services into the mainstream provision of NHS services. However, we are still a long way from that. Mental health is not treated in the same way as other services. But we put that into public policy in February 2011, when we said:
“We are clear that we expect parity of esteem between mental and physical health services”.
It was a cross-cutting strategy that was intended to deliver that parity.
As the noble Lord pointed out, why do I and all other former Secretaries of State going back 20 years feel a sense of distress and sometimes despair about our ability to produce precisely that result? I think the answer is that the structures, funding and culture have not yet accepted that mental services should be brought into the mainstream, with all the benefits that that would bring. In my experience as a Secretary of State, mental health trusts were often extremely well run organisations, even by comparison with other community healthcare services. That is why I was so disappointed that the Uniting Care Partnership contract for Cambridgeshire and Peterborough, which faced severe problems from the outset and then collapsed, did not bring acute community and mental health services into one organisation, which would have been really useful.
We all support and want integration of services, but it is not happening in many places, and even where people put the services under a single umbrella, they often do not achieve integration of the professions. Least of all do they provide the integration that should be at the heart of the patient experience, so that people feel that health services are being provided by an organisation that works around them, not to its own structures and definitions. We have a long way to go to make that happen. Another real concern is that we have failed to achieve integration, notwithstanding successive requirements in recent years from government and NHS England for commissioners to increase funding for mental health services at least as fast as for the service overall.
I have to say that, although there were some announcements in September by NHS England and NHS Improvement, the structure of funding to the National Health Service from commissioners plays a part. Most of the time, most of the NHS is funded on the basis of tariff. To that extent, in so far as somebody receives a service from a provider, the provider has recourse—sometimes not enough, they think—to the commissioners to provide for that activity. Mental health trusts are pretty much still all under block contracts. As I said, an effort has been made since September to extend tariffs into mental health services. It should be done on the basis not of episodes of care, but of bundled care and care pathways. When that happens, it will enable mental health trusts to escape from this situation: because commissioners know they have to pay for the tariffs, such trusts are often provided with the residual sum, which means they do not get the funding they could for the activity they undertake.
My colleagues and I could see some of the problems: the number of suicides among young men aged under 45; people having to travel great distances to access care; and rising levels of mental health problems among young women. These and other issues are presenting us with problems. We know we can change the culture. Time to Change, for example, was a very successful programme that continues to be extremely useful, and we now have access standards for mental health services. However, I ask the Minister to take back these questions. How much progress has been made so far in 2016-17 in securing those access standards? How much further do we have to travel? When will we be told what the objectives will be in 2017-18 and 2018-19 for measuring progress towards the 2020 objectives in the mandate for securing access to mental health services?
There is more we can do. We can extend the access standards. We need more quality standards applicable to mental health—the forward programme has only one, although the number published by NICE is valuable. It feels to me and my colleagues that we have much further to go and we need to inject a sense of urgency. That is why I welcome the debate.
My Lords, I am grateful to my noble friend Lord Alderdice for initiating the debate. It is obvious that no one on the Government Benches or on this side of the House will argue that there should not be parity between physical and mental health. As my noble friend said, that commitment was put in legislation by this House in 2012. It is enshrined in the NHS mandate and on the lips of politicians of almost every political hue. But it is one thing to will the ends and quite another to will the means. Despite so much debate and so much agreement, we are still a very long way from providing the means to achieve the end we all purport to support.
Of course, it is naive to think that parity of esteem between mental and physical health can be achieved overnight. I am the first to recognise, as my noble friend and the noble Lord, Lord Lansley, made clear, that money alone is not in itself an answer. There are complex issues related to culture, staffing, training, and effective data and reporting systems. Change is needed not just in our health services but in our education services and in the services provided by a wide range of authorities. It is true that money alone will not change things, but it is also true that without the requisite funds, none of the other things that need to happen can or will happen—and all the time they do not, thousands of lives will continue to be lost and millions more will remain hobbled by mental ill health.
It may be that we cannot achieve parity of esteem overnight, but that is no excuse for complacency. Let us never kid ourselves that we have the luxury of time, because every month we delay, every service we fail to provide and every person we fail to treat adequately has an impact that can last a lifetime. So whatever the response from the Minister this evening, I hope it will recognise the desperate, life-threatening urgency of what we are discussing today.
The Mental Health Taskforce’s five-year forward view reported that suicide deaths are rising after many years of decline: 4,882 deaths by suicide were reported in 2014. That is nearly 2,000 more people than were killed in the horrific attacks on America on 9/11—and it is not a one-off event. It is a death toll happening year after year, a tragic waste of the lives of so many precious people and a terrible toll of grief on so many families and friends. Such is the scale of this tragedy that suicide is now the leading cause of death for men aged 15 to 49. The five-year forward view reports that in recent years the rise in suicides among middle-aged men has been particularly acute.
Those who listened to Radio 5 Live’s “Five Live Investigates” programme on eating disorders yesterday morning will also have heard of the terrible inadequacy of treatment in many areas of the country for those suffering from such disorders. They will have heard of the parents in Oxfordshire forced to make an 800-mile round trip to visit their daughter who could be provided with the care she needed only in Glasgow. That is the level of inadequacy we are dealing with. Those of us—and there are many, I know—who have people dear to them who have suffered from such disorders will know the absolute desperation of parents, family and friends when you cannot get the access to services that are so desperately needed. Those listening to that Radio 5 Live programme will also have heard the research carried out by the programme that indicated that there had been a 65% increase in deaths from eating disorders since 2014.
Of course, it is not just the young and middle aged who are suffering from mental ill health. Older people are, too, particularly those in care homes, 40% of whom are affected by depression. We all know how very far we are from achieving parity of esteem and we need to be very clear with ourselves about the very real and often irreversible impacts on people’s lives that our failure represents. Of course, we should not ignore the very important steps forward in recent years in tackling the stigma of mental ill health and in putting parity of esteem firmly on the agenda. I pay tribute to the many people, of all parties and none, who have made such efforts in that regard, not least the noble Lord, Lord Lansley, who mentioned Paul Burstow and Norman Lamb and other Ministers, including Ministers of other parties, who have shown great commitment to this issue.
Like my noble friend, I wonder how much progress we are actually making. The introduction of waiting time standards and the injection of new resources has been welcome, but there are very worrying signs that the extra money is not getting to the front line. The briefing we have received from the King’s Fund shows that 40% of mental health trusts continue to experience year-on-year cuts to their budgets as the demand for their services increases. With 80% of mental health care provided through the trusts, it is hard to see how we will reach parity of esteem with this approach. It is equally hard to understand how we will deliver the quality and choice of provision that are needed.
The British Association for Counselling & Psychotherapy report, Psychological Therapies and Parity of Esteem, cited NICE research that, of all those receiving treatment in the NHS for common mental health disorders, only one in seven receives psychological therapy; the majority are prescribed medication, despite the fact that most patients say they would prefer talking therapy; and there is no requirement on commissioners or providers to deliver the full range of NICE-recommended therapies. Only one in five service users who responded to the BACP survey had been offered a choice of therapy. As Paul Burstow said when Minister for Care Services in 2010:
“At the moment, IAPT is a little too much like Henry Ford’s business philosophy … you can have any therapy as long as it’s CBT”.
Both my noble friend Lord Alderdice and the noble Lord, Lord Lansley, have been clear that we need to look beyond funding and structures to cultural and societal issues. I agree wholeheartedly with the noble Lord, Lord Lansley, that mental and physical health should not be seen as separate things. Nevertheless, we cannot ignore the resourcing issues, so perhaps the Minister might address a couple of questions. First, what are the Government doing to ensure that funding actually gets to the front line? Secondly, what measures are they taking to ensure that we have effective data on what is actually happening in the NHS with regard to mental health? Thirdly, what are the Government doing to ensure that the range of IAPT therapies are available across the country?
Dr Michael Shooter said in his introduction to the BACP report:
“You will not meet your commitment to parity of esteem for mental health without a significant increase in the quantity and quality of the provision of psychological therapies. If you are serious, this is what you must do”.
I hope that we are serious and that the Minister will tell us that that is what the Government will do.
My Lords, I, too, thank the noble Lord, Lord Alderdice, for introducing the concept of parity in such an interesting way. I admit to being delighted that my amendment to the Health and Social Care Act has contributed to moving mental health issues up the political agenda, with a commitment to parity of esteem. I declare an interest as a former president of the Royal College of Psychiatrists, a former consultant psychiatrist and emeritus professor of psychiatry at St George’s, University of London. I also steered the development of the British Medical Association report published in 2014, Recognising the Importance of Physical Health in Mental Health and Intellectual Disability: Achieving Parity of Outcomes, and I will return to that in a moment.
Parity also means that if a diagnosis of a mental health problem has been made, investigations and treatment should be provided on an equal basis, as they would for a physical health problem. But we know that this is not happening yet, and one reason for this is because evidence-based tests and treatments for mental disorders lag behind those for conditions seen as purely physical. There has been an unacceptable underresourcing of research into the understanding and treatment of mental illness, and this is really important.
Another aspect is the physical health of people with severe mental illness, who face earlier death than people without. As with people with learning disabilities who experience earlier mortality, discriminatory attitudes are probably partly responsible. In July this year, the United Nations Human Rights Council adopted a resolution on mental health and human rights, which highlighted that,
“persons with mental health conditions or psychosocial disabilities, in particular persons using mental health services, may be subject to … widespread discrimination, stigma, prejudice, violence, social exclusion and segregation, unlawful or arbitrary institutionalization, over-medicalization and treatment practices that fail to respect their autonomy, will and preferences”.
I think this is relevant to tonight’s debate.
I have long been an advocate of liaison psychiatry teams in acute hospitals. The announcement by Simon Stevens of a new standard for mental health care is to be welcomed. It says that,
“anyone who walks through the front door of A&E or is on a hospital ward in a mental health crisis should be seen by a specialist mental health professional within an hour of being referred”.
This includes mothers in maternity wards. We should not underestimate how hard this will be to achieve, because it will require not only a change of attitude among health professionals and a change in the culture of hospitals but a completely different way of commissioning and providing mental health services. The standard demands that patients should,
“within four hours … have been properly assessed in a skilled and compassionate way, with the correct next steps for their care planned in partnership with them”—
and, I hope, with their family or partner when relevant.
For me, two very important words in this announcement bear careful thinking about. One of these is “compassionate”. We have spoken about compassion many times in this House in connection with the report of the Francis inquiry but not in connection with parity of esteem. In the department of psychiatry at Harvard Medical School, the idea of Schwartz rounds developed—and these are now being used in some hospitals in the United Kingdom—to provide an opportunity for staff from all disciplines to reflect on the emotional aspects of their work. I suggest that this type of approach is fundamental to breaking down the barriers to the acceptance and understanding of mental distress in our hospitals. In part, their success is because they are looking after the very staff who are working in an environment where mental distress is perhaps not understood, whether it relates to the patient or to the staff themselves. Another initiative that the department at Harvard is researching is whether empathy can be taught to clinicians, with a particular focus on non-verbal aspects of communication.
The second key word in the announcement is “biopsychosocial”, and all three parts of that word must be addressed. A key point about parity, which has already been mentioned in this debate, is that we cannot and must not think about mental and physical illness separately any longer. My main concern about our failure to achieve parity is that we are still separating the mental and physical parts of ourselves in such an unhelpful and inaccurate way. It is almost as if our hearts and our minds are in different bodies, and that the social context in which we live our lives is of no importance.
In current discourse, physical illnesses are seen as biological in nature and in need of biomedical tests and interventions, while mental illnesses draw on neuroscience explanations as well as social and psychological ones. In reality, both mental and physical disorders need to draw on biopsychosocial formulations and responses. The problem arises when medical practitioners fail to make the connections. In many ways, this is not surprising given the current separation of services between different provider organisations and the too-early separation of clinical training into physical or mental. Yet we know that people with mental ill-health are three times more likely to end up in A&E than the general population, and five times more likely to be admitted to general hospital wards in an emergency. Is any more evidence needed for the provision of skilled mental health practitioners to be present in the acute hospital, on an equal footing with other specialists?
The NHS has published an aide-memoire on what every sustainability and transformation plan needs to consider in relation to mental health and dementia. The Royal College of Psychiatrists believes this aide-memoire to be a very important guide. Can the Minister say what the Department of Health has done to promote this document and to ensure that local areas take the advice,
“to think more holistically across mental and physical health, rather than just”,
in terms of a separate “mental health ‘section’”?
Does the Minister also agree that the Government have a duty to address the urgency of the fact that 46% of people with serious mental illness have a long-term physical health condition and are at risk of losing, on average, 10 to 20 years of their lifespan due to physical ill-health? Will the Minister explain how in practice the Government’s policy is expected to have an impact on reducing premature mortality? Will the Minister also tell the House what measures are being taken to increase the essential research funding which will underpin any chance of success in this policy initiative?
Will the Government commit not to sign off any sustainability and transformation plan that does not have a clear plan for improving services for children’s mental health? I have not spoken specifically about children or about people with learning disabilities or autism, who have a much higher prevalence of mental illness.
My final comment relates to the urgent need for more attention and money to be given to creating safe and supportive environments and providing skilled support at home for all people with mental health problems and to take seriously the psychosocial part of the word “biopsychosocial”.
My Lords, I, too, welcome the opportunity to take part tonight. I refer noble Lords to my interest as leader of North Lincolnshire Council, which is set out in the register. I thank the noble Lord, Lord Alderdice, for tabling this Question. We all want to highlight the importance of the very real issue of parity between mental and physical health. Unfortunately, in the past mental illness has been classed as a Cinderella service which has been underfunded and not meaningfully discussed for decades, so I welcome the Government’s intervention with an additional £1 billion per year in real terms by 2021. I fervently hope to see a more collaborative approach to parity of mental and physical health.
I was personally involved as a guardian to a young person who suffered from schizophrenia. I tried to support him to live independently in his community. Sadly, he died prematurely. A concern was how people related to him. It was at many times challenging for him, and for others. People’s fixed views were not always encouraging. Access to services could be difficult at times. Barriers are beginning to be dismantled, particularly the general public’s attitude. Overcoming stigma and discrimination is supporting this approach. Celebrities, politicians, sports stars and a whole army of campaigners and activists are now speaking openly and calling for better treatment, culminating in a desire massively to improve this service.
We have one life, so when we read statistics showing that people who suffer severe mental illness die on average 15 to 20 years earlier than the general population because of poor physical health, quite rightly there should be a call to do something—a call to action. We need a first-class delivery vehicle equipping, upskilling and increasing our mental health workforce. It is critical that we get it right in terms of numbers, skill mix and appropriate training to see service improvement and to support those professions. It is also important to have written care plans assessed annually with input from carers and supporting organisations. Care plans should include priorities of public health and concerns such as tobacco, alcohol and obesity. We know that poor mental health is associated with higher rates of smoking and, in particular, with substance misuse problems.
I particularly highlight prisoners in our criminal justice system. After they have entered prison, large numbers of men and women are diagnosed with a diagnosable mental health problem. From the viewpoint of those facing long sentences, their life has fallen apart. When those men and women leave the criminal justice system a direct referral to the NHS would help and should be offered. Not everyone leaving prison will choose that option, because of their distrust of professionals; nevertheless, the opportunity should be available. Bridging the gap at that point would allow other organisations, including local government, to take part as part of a prevention agenda, in particular helping with housing and signposting other services. As we know, good-quality housing is important to give not just comfort but stability and focus for people suffering from mental health issues.
I mentioned stability, and a place. We all need a place—a home to connect to a community—to belong to a community, which can contribute to a person’s well-being. There is also a need for a really good work programme, which will forge and enhance esteem. Mental health problems are one of the most significant barriers preventing people on benefits from taking up employment, so there is a need to look at how the benefits system supports them and to focus more on improving mental health—a new, integrated approach between work and health. As we all know, it is okay getting that job, but this is about keeping it, because we know it benefits people’s health and mental health. Building relationships and making new friends offers an opportunity to address loneliness and could help bring down those high rates of suicide, which remains the biggest killer of men under 45. All this comes into the equation for a better life chance for people suffering from some form of mental illness.
In the time allocated, I have focused on a particular age group and section of our population, but with mental health issues affecting all ages, from our younger generation to our older generation, we need to make a real difference and really push this. I hope that with the Government’s budget increase we will see a difference. I see a change happening and, building on that premise, we can pledge our support for more prevention. With this timely debate tonight, we are responding to and highlighting the very real and personal issues affecting mental illness and offering support for parity of esteem for mental and physical health for all. I very much welcome this debate tonight.
My Lords, this subject has been raised before, and I thank my noble friend Lord Alderdice for raising it once again. It is a crucial matter that has to be examined frequently—or, shall I say, continuously. We are living through a period when, time and again, there is concern about the funding of the NHS as a whole. Is it adequate or not? We need to be very concerned about parity between mental and physical health.
Mental health issues are not always taken seriously because, unlike physical conditions, they cannot always be seen, and it is only in recent years that the extent of the problem has become a national issue. One in 10 of five to 16 year-olds has a diagnosable mental health problem. It is also the greatest reason for death in young men, as has been mentioned. A mental health problem can start early and be a lifetime issue.
I will address one specific area of mental health, CAMHS, which stands for child and adolescent mental health services. I understand that every town or area in the country has a CAMHS team, and the concern is whether funding intended specifically for the CAMHS team is always being kept for that team. Can the Minister look into this? There is concern that CAMHS funding specifically intended for that role has been used to plug problems in local areas with local hospitals and suchlike. Is CAMHS funding, which is so important to address this issue, always being ring-fenced?
I want to repeat concerns that were raised earlier this year when The Five-Year Forward View for Mental Health was published by the Mental Health Taskforce. I draw this independent report again to the Minister’s attention. Its foreword says:
“For far too long, people of all ages with mental health problems have been stigmatised and marginalised, all too often experiencing an NHS that treats their minds and bodies separately. Mental health services have been underfunded for decades, and too many people have received no help at all, leading to hundreds of thousands of … tragic and unnecessary deaths”.
I urge the Government to look at that report again and be aware of the need to address the whole issue of mental health.
Previously in debate, a government Minister said that he agreed that the Government and Ministers needed to be held to account once or twice a year. I am glad to have taken part in this very necessary debate to hold the Government frequently to account. On that note, and with my concern about local funding for the help that is needed for children and young people, I urge the Minister, as we all do, to look into these problems.
My Lords, I congratulate my noble friend Lord Alderdice on securing tonight’s debate, which provides a timely opportunity to consider one of the most fundamental issues in healthcare today. Efforts to achieve equal value of physical and mental health span many decades. The Royal Commission of 1957, the year of my birth, noted, not quite in today’s language, that:
“Most people are coming to regard mental illness and disability in much the same way as physical illness and disability”.
That was almost 60 years ago.
In recent times there has been a welcome shift in public attitudes towards mental health and a growing commitment among communities, workplaces and schools, and within government, to change the way we think about this issue. As we know, there have been a raft of commissions and taskforces as well as Future in Mind, looking at young people’s mental health, and of course the recent Five-Year Forward View for Mental Health. They have provided many important recommendations on how we can achieve genuine parity of esteem. They have all stressed, as has been stressed tonight, the inextricable link between mental and physical health. What does that actually mean? To help define this, I looked back at the All-Party Parliamentary Group’s very good report last year on parity of esteem. It said:
“What this would mean in practice is that taking a holistic view of an individual’s health (seeing the interdependencies between both their physical and mental health needs) would be the norm”.
Having listened carefully to my noble friend Lord Alderdice, I would add “health and well-being”.
The fundamental question for us is why it has been so difficult to achieve real and sustained progress. I did a quick survey of the scene, and many aspects I did not find very reassuring. As Michael Marmot so powerfully reminded us in his recent book The Health Gap: The Challenge of an Unequal World, people with mental ill health have a life expectancy between 10 and 20 years shorter than people with no mental illness. I am sure we all find that shocking.
Only a quarter of those with mental illness such as depression are receiving treatment, a figure that contrasts with 78% of those with heart disease and 91% of those with high blood pressure. A recent CQC report noted that, when facing a crisis, a shocking 32% of people do not know who to contact out of hours. Indeed, 24% of those who did know said they did not receive the care they needed.
It is not all doom and gloom—there has been some progress. Thanks to the persistence particularly of Liberal Democrats in the coalition Government, the first ever mental health waiting time standards were introduced. This was a real achievement and helped to bring mental health services into line with other NHS services, such as cancer and A&E waiting times. It was a tangible step on the journey towards parity of esteem. However, as the Mental Health Taskforce report earlier this year noted, for first appointments and for the right follow-on support, waiting times are still “unacceptably long”. Only a couple weeks ago, the Education Policy Institute’s report Time to Deliver found that only 18% of areas were meeting the four-week waiting times for routine cases and only 14% were meeting one-week waiting times for urgent cases. The noble Lord, Lord Lansley, drew attention to this lack of progress, and I very much look forward to hearing what the Minister has to say.
A number of factors underpin that lack of progress, and I want to focus first on the problems of funding, both disparity and historical underfunding. To their credit, the Government committed £1.25 billion to children and young people’s mental health over the next five years, which is £250 million a year. Despite that commendable promise, only £143 million was released in the first year and of that, only £75 million was actually distributed to clinical commissioning groups. Even less got to the front line.
As we have already heard, last year, across the board, 40% of NHS mental health providers had their funding reduced, despite NHS England instructing commissioners to increase it. This raises serious questions as to whether funding is reaching the areas where it is most needed, and it highlights the damaging impact of the Government’s refusal to ring-fence mental health funding. I know Jeremy Hunt said that he does not have the power to do that, but frankly, Governments, if they are so minded, can do something about it if they do not have the powers.
It is the same story with the £1 billion announced last year for mental health, much of which does not come on stream until the end of this Parliament. One could be forgiven for assuming that in last week’s Autumn Statement, the Chancellor would have offered a lifeline to mental health services, as well as other areas of health and social care. Instead, the Government found £240 million for the expansion of grammar schools, but not a penny for the NHS.
On a more positive note, the introduction of the five-year forward view included dashboards, an initiative welcomed by the Royal College of Psychiatrists. I, too, welcome them as representing a viable solution to ensuring better accountability and transparency from clinical commissioning groups. Obliging CCGs to publish facts and figures on their spend on mental health and the services they deliver will go some way to addressing the funding disparity, and stop money intended for mental health being siphoned off elsewhere. What is being done to publicise and promote the CCG dashboards, and how will people be able to compare the performance of their local CCG with others in other parts of the country?
Funding impacts on other factors which are also preventing parity of esteem. The mental health sector, in particular, is suffering from recruitment and staff morale problems. As noted in the report of the noble Lord, Lord Crisp, on acute adult psychiatric care, Old Problems, New Solutions, these problems are in part due to disproportionate financial cuts. The same report found an 8% decrease in the number of mental health nurses between 2010 and 2014, while there was a 1% increase in physical healthcare nurses over that period. Given that NHS England estimates that implementing access and waiting time standards will require a 7% increase in the number of mental health nurses by 2020, how do the Government expect to achieve that standard without staffing levels rising?
It is not for lack of ideas, recommendations or reports that progress on parity has been unsatisfactory—nor is it, as many other noble Lords have said, solely about money. There are other, non-financial issues, including cultural issues, and that provides the starting point for the Values-Based Child and Adolescent Mental Health System Commission, which I had the privilege of chairing. Its report, published on 7 November, explores how different values drive deep-seated culture, attitudes, decision-making, practice and behaviour—the invisible drivers, if you like—which can either inhibit or promote a truly system-wide approach to redesigning and transforming services. The report’s 10 recommendations were all about how a more explicitly values-based approach with a shared language could really improve the mental health and well-being of children by focusing single-mindedly on what really matters to them. That report, and the recent report Time to Deliver, by the Education Policy Institute, chaired by my right honourable friend Norman Lamb, had a number of important recommendations. In particular, it proposed that the Prime Minister should announce a national challenge on children’s mental health. Can the Minister indicate how the Prime Minister intends to respond to that recommendation?
In conclusion, we should aim to achieve a healthcare system in which parity of esteem means that mental healthcare is not only as good as physical healthcare but is delivered, as the recent King’s Fund report recommends, as part of an integrated approach to health and well-being, as my noble friend Lord Alderdice so powerfully reminded us this evening.
My Lords, it is a great pleasure to wind up for the Opposition tonight and congratulate the noble Lord, Lord Alderdice, on what can be described only as a powerful tour de force. It was a fascinating insight into parity of esteem, as he saw it, in Northern Ireland more generally, which set the context for our debate. Almost all noble Lords have agreed with his proposition that, despite any number of pronouncements, policies and changes in the law, mental health continues to be a Cinderella service. Certainly, my impression of mental health services is that, although they came as part of the health service in 1948, although in the original structures they had their own hospital management committees, which were brought into area health authorities and then district health authorities—and then there was the development of NHS trusts and foundation trusts—and although they were in some cases integrated with those organisations and in some cases were not, they remained invisible throughout. It is a service that continues to be invisible when it comes to the key policy decisions that the Government, NHS England and the regulators make on the health service.
From a managerial point of view it is my impression that, once you become a manager in a mental health service, you stay a manager there—you do not move over. You are not perceived to have the qualities needed to become a leader in a more acute trust. If you look at the NHS people seconded into the department, NHS England or the regulators, you can see how few of them are experienced in mental health services. The noble Lord, Lord Lansley, suggested that this was rather underpinned by the financial system of mental health services whereby, because there is no tariff-based system, clinical commissioning groups tend to negotiate around the tariff and then what is left goes under block contracts to mental and community health services. This puts them at a disadvantage.
Although structures are not important, there is an issue in relation to both the culture and some of the structural issues which seems to account for the lack of focus on and priority for mental health services. Yet my experience when I chaired an acute NHS foundation trust was that many of the challenges we faced were because of the lack of proper support for patients with mental health problems. In any emergency department there will be a huge number of people with these issues. Unless there are properly based mental health services, working side by side with the acute trust, you end up with people inappropriately cared for in inappropriate places, with their outcomes often getting worse and worse.
The noble Baroness, Lady Hollins, asked the Minister a very good question about the sustainability and transformation plans. She thought that the department should not sign off STPs unless it was satisfied that the principles of parity of esteem were fully embraced within them. That is a very good suggestion which I hope the noble Baroness will agree to consider. I have looked at the names of the leaders of the 44 sustainability and transformation plans. They are clearly eminent people, many of whom I know, so there is no doubt that NHS England has appointed people of high calibre. However, they are mainly chief executives of acute trusts, clinical commissioning groups and, in one or two cases, local authorities—particularly Birmingham and Manchester. Why is this? Why have we not turned to mental health chief executives to lead some of these STPs? In my experience, mental health services often know a lot about the system because their clients impact on so many aspects of the service. If we want to make a real, visible indication that mental health services are important, we should look for leaders from mental health services to lead the sustainability and transformation plans. Even if that does not happen, I hope that both NHS England and the Department of Health will ensure that legal requirements for parity of esteem are applied before they are signed off. More than that I hope it is recognised that, unless you put mental health right at the heart of these plans, the ambitions in them are very unlikely to be realised.
I will briefly come to the question of finance. We know that the Government have ordered the NHS to put more money into mental health services. We have heard from noble Lords about the commitment for £1 billion more for mental health by 2020-21. We also heard from the noble Lord, Lord Prior, only last week, that the spend on mental health in 2015-16 is up by 8.4% on the previous year. He said that,
“there is clear evidence that the money that we have been talking about is getting through”.—[Official Report, 16/11/16; col. 1417.]
Yet most noble Lords who have spoken would say that they disagree that the money is getting through to the front line. I do not know whether the Minister has seen the recent work by the Royal College of Psychiatrists on mental health services for children and adolescents. It points out that 52 CCGs in England are allocating less than 5% of their total mental health budgets to services for children and young people. We know of the horrendous problem of young people having to be sent to places hundreds of miles away from their homes because of a lack of facilities. We have also heard, from other noble Lords, that the money simply does not seem to be getting through to other mental health services. Is the noble Baroness assured of the accuracy of the returns made by the NHS to her department on the sharing out of the mental health budget, because there is a suspicion that there has been a rebadging of existing programmes to massage the figures to make it look as though mental health spending is up when the clear experience on the front line is that services are being squeezed and squeezed?
I do not doubt Ministers’ good intents in regard to mental health and ensuring that parity of esteem is achieved. However, the reality is that on the front line mental health services continue to be discriminated against and services are under great threat. There is great concern that in the major changes we are going to see in the health service in the next two or three years as a result of the sustainability and transformation plans, mental health, far from being at the core of the changes, will once again be treated as the neglected hidden Cinderella service. I hope that the noble Baroness can prove us wrong.
My Lords, this has been an absolutely fascinating debate. As always, many experts have spoken on the subject. I will do my best to answer many of the questions—but I am certainly not the noble Lord, Lord Prior, who is the expert on this issue. If I fail to answer all the questions asked by noble Lords, I will make sure that we get back to them in writing.
I congratulate the noble Lord on securing this debate on parity of esteem between physical and mental health. I know that he has a keen personal and professional interest in this subject. I thank everyone who has contributed to this debate. I will answer their questions at the end of my speech.
The publication of the independent Mental Health Taskforce’s Five Year Forward View for Mental Health in February this year has stimulated discussion and debate across both Houses. As we know, mental ill health is something that can affect any one of us: one in four of us, according to the latest figures. Yet despite the prevalence of mental health problems, the stigma associated with mental health persists, so creating a barrier to people talking about mental health problems and seeking help. We know this only too well. Whenever I go out for a meal with friends, within five minutes everybody is talking about their arthritis—as we are all getting so old in this House—or their recent operations. But how often do people ever say, “Actually, I had a breakdown two years ago”, or, “I have been seeing a counsellor because I am worried about my child who has autism”? Very rarely are these issues brought up. We have a lot to do to try to make those conversations as normal as ones in which people talk about their physical health.
We are committed to tackling this stigma and this year announced a further £12.5 million of support to the national Time to Change anti-stigma programme up to 2020-21, which seeks to change attitudes to mental health. Indeed, since the programme began, about 3.5 million people have reported improved attitudes to mental health.
Mental ill health is still the single largest cause of disability, costing the UK economy around £105 billion per year, and represents 23% of the overall UK health burden. The coalition Government enshrined parity of esteem in the Health and Social Care Act 2012, as the noble Baroness, Lady Tyler, said. They also introduced the first mental health waiting times standards for access to psychological therapies in 2015 and early intervention in psychosis from 2016. These are being met by the majority of the NHS.
Following on from that, we are on the cusp of an ambitious transformation programme in mental health. But, as my noble friend Lord Lansley said, we have to recognise the scale of the challenge. As all noble Lords are only too aware, we are starting from a very low base due to chronic historical underfunding of the service. As the noble Lord, Lord Alderdice, mentioned, mental health has been the Cinderella of healthcare. We are now investing unprecedented amounts in mental health and require CCGs to continue to increase their spending on mental health each year. We have set out additional investment to transform children and young people’s mental health of £250 million each year up to 2020-21 and have set out additional investment to improve services for eating disorders, bringing the total investment to £1.4 billion by 2020-21.
Alongside this, as the noble Lord, Lord Oates, mentioned, we are working across government to deliver a robust five-year mental health data plan to substantially improve data and information about mental health services and young people. But this is not just about data collection and funding; proper investment in the workforce is absolutely essential. So we are working with Health Education England as it develops a workforce strategy, expanding both the skills of existing staff and the workforce itself. Work between the department and NHS England is ongoing to make the best use of mental health beds to ensure that people who need them can get them close to home. We have funded an extra 56 mental health beds for children and young people.
We know that the role of front-line services, including primary and community care, is paramount, particularly for those in crisis. NHS England has invested in crisis resolution and home treatment teams to provide effective intensive home treatment as an alternative to hospital admission. As several noble Lords, including the noble Lords, Lord Oates and Lord Alderdice, mentioned, primary care has a vital role to play in helping people before they even reach a crisis. The taskforce report recommended that by 2020 all GPs should have mental health training, which of course we support. Leading on from this, we have also invested heavily in liaison psychiatry services in emergency departments for patients in crisis. This will save an average hospital £5 million per year by reducing the number and length of admissions to beds. As the noble Baroness, Lady Hollins, mentioned, even more important is the potential for those in crisis to be seen and treated at an early stage. The department has funded nine pilots for street triage, managed by police forces working with NHS front-line partners. Nearly all the street triage pilot schemes resulted in a reduction in the use of Section 136 detentions. All these areas continued the service after the pilots finished. Today, 39 out of 40 police forces in England have access to a street triage service.
Public Health England is developing a mental health prevention concordat focusing on suicide prevention which will be published next year. We will strengthen the cross-government suicide prevention strategy, including addressing self-harm. NHS England will develop an evidence-based treatment pathway for self-harm during 2017-18 and 2018-19. We also plan to roll out liaison and diversion services nationally by 2020-21, ensuring that people who come into contact with the criminal justice system have their needs assessed, thus helping magistrates and judges divert vulnerable offenders to the most appropriate place of treatment. This work is already beginning to have some success—and I can endorse that. I work closely with an addiction charity in Gloucester, called the Nelson Trust, and it accepts exactly these kind of vulnerable people into the charity’s care for treatment, having been referred from the CJS.
The department and NHS England will continue accountability and ensure equal priority for mental and physical health through a number of mechanisms, such as the CCG improvement and assessment framework and the five-year forward view for mental health dashboard. These will monitor progress on commitments to transform mental health services, and the public availability of data will improve accountability for patients and the public.
I want to cover some of the points that have been raised. My noble friend Lord Lansley asked how much progress has been made for 2016-17 in securing access standards and when people will be made aware of the objectives for 2017-18. We have standards on IAPT access and on EIP and CYP eating disorders, and further plans for developing pathways are set out in the NHS England task force’s implementation plan. Independent experts at the Royal College of Psychiatrists are reviewing and supporting implementation and will report next year.
The noble Lord, Lord Oates, talked at length about suicide, and the noble Lord, Lord Cotter, also referred to this. It is a very important point. As noble Lords will know, the Five Year Forward View for Mental Health set out the ambition that the number of people taking their own lives will be reduced by 10% nationally compared with the 2016-17 level. To support this, by 2017 all CCGs will contribute fully to the development of the plans.
We are absolutely committed to improving access to mental health services. We introduced the first waiting times for mental health talking therapies—mentioned by the noble Lord, Lord Oates—as well as early intervention in psychosis. By 2020-21 we will implement a comprehensive range of community-based mental health pathways of care and standards. We are also expanding access to the successful talking therapies programme so that by 2020-21 a further 600,000 people will be able to receive the care they need.
The noble Lords, Lord Oates and Lord Cotter, also mentioned children and young people. By 2020-21 there will be a significant expansion of access to high-quality mental health care for children and young people. At least 70,000 additional children and young people each year will receive evidence-based treatment, representing an increase in access to NHS-funded community services to meet the needs of at least 35% of those with diagnosable mental health conditions. To support this objective, by 31 October 2016 all local areas should have expanded, refreshed and republished their local transformation plans for children and young people’s mental health. Refreshed plans should detail how local areas will use the extra funds committed to support their ambitions across the whole local system.
The noble Lord, Lord Hunt, and the noble Baroness, Lady Hollins, mentioned tariffs and funding. We recognise that block contracts are an issue and make it less transparent. We are working to address this. NHS England has proposed new payment approaches for adults and older people. These outcome-based payment requirements focus on improvements of care by linking payment to quality outcomes.
I think I have covered most of the questions asked. If not, I will of course write to noble Lords. What has really come out tonight is that it is not as simple as legislating for or discussing these issues. We must work with the NHS professionals and beyond to truly establish equal priority for mental and physical health. As the noble Lord, Lord Alderdice, said, this needs to be a cross-party, multifaceted approach. We need to challenge the stigma surrounding this issue and look at the role of primary care, which is paramount in this. I thank noble Lords again for all the points raised in the debate.
House adjourned at 7.44 pm.