Question for Short Debate
My Lords, since this business is time limited, I draw noble Lords’ attention to the fact that the clocks that normally flash are not doing so, so we have reverted back to the older model which will require noble Lords taking part in the debate to exercise the customary discipline in recognising when their time is up.
My Lords, I declare an interest: one of my daughters suffers from anorexia. We have experienced NHS eating disorder services both for children and young people and for adults in the community, and specialist in-patient care, and it is clear to me that while advances have been made, insufficient progress has been made to date in improving the care for people suffering from these life-threatening diseases. Noble Lords should be in no doubt that they are serious mental illnesses. They can cripple lives physically, emotionally, socially and can ultimately take them. Anorexia has the highest mortality rate of any mental illness and, like cancer, if eating disorders are not caught early, they are much harder to treat.
There are waiting-time targets for children and young people to access eating disorder services, but none for adults. The Royal College of Psychiatrists found that people can wait up to 41 months for treatment, with adults waiting up to 30% longer than those under 18 years of age. Those delays to get treatment have devastating and life-threatening results, like the death of Averil Hart aged just 19 from anorexia. Her death and those of two other young women were investigated by the Parliamentary and Health Service Ombudsman in 2017 and followed up by the House of Commons Public Administration and Constitutional Affairs Committee in 2019. Both those inquiries found that it was time to ensure that young people and children’s services were in parity with those provided for adults. I am delighted that the Government are now piloting a waiting time for adults to receive eating disorder services. But when those eight pilots end next year, there is no ring-fenced money in the budget for adult mental health up until 2024 to roll out a national scheme for adults for a waiting time standard. Given that it is now three years since the first inquiry said that this was a matter to be treated with urgency, will the Minister say when the Government think it will be possible to roll out a national waiting time standard for adults with eating disorders?
It is not just about having access to early treatment. It also about ensuring that when people go to their GP there are medics who know how to identify, manage and safely refer those patients. Research in 2018 by Dr Agnes Ayton showed that on average there is less than two hours of medical training on eating disorders, with one in five medical schools offering no training whatever. Ellen Macpherson, a final-year medical student in Manchester, says:
“I’ve had around 10 hours of teaching on schizophrenia, which affects one-fifth of the numbers affected by an eating disorder and has half the mortality rate.”
A survey of medical schools by the General Medical Council echoed Dr Ayton’s research. It concluded that doctors are not sufficiently prepared to manage patients with eating disorders. Recent initiatives by the GMC are welcome, but progress is painfully slow. When she responds, will the Minister tell us how the Government are ensuring that the GMC, medical schools and the royal colleges are undertaking their responsibility to ensure that medical professionals are teaching people properly about these life-threatening diseases?
There is also a need for more research. There are excellent examples of clinic-based treatment here in the UK. When I recently visited the South London and Maudsley NHS Foundation Trust I heard about FREED—first episode and rapid early intervention for eating disorders—and I was told about how early intervention and evidence-based treatments can work, but we still do not have a full understanding of, or know how best to treat, eating disorders.
Research levels for mental health are woefully low. Analysis from the charity MQ recently identified that just 96p per person affected is spent on eating disorder research, whereas a physical health condition which affects twice the number of people receives £228 per person affected. When will the Government review the level of funding given to mental health research? Only by looking at funding as well as services will we deliver the parity of esteem for mental health enshrined in legislation by the coalition Government, and the Government have made welcome signs that they are still committed to that.
Recruiting and retaining staff is also a real challenge, given the pressures, especially in adult services. The Royal College of Psychiatrists survey showed that vacancy rates for psychiatrists have more than doubled in the past six years and eating disorder services are among the most seriously affected services. In England, there are only 81 psychiatric posts in eating disorder services, and last year 12 of them were vacant. This directly impacts on the time people wait for treatment. While NHS England and NHS Improvement have been tasked with ensuring that local plans are drawn up to meet staffing requirements for mental health, they will not be able to deliver them unless some of the underlying reasons causing those shortfalls are addressed. This may be an issue that the noble Baroness, Lady Hollins, will touch on, so I shall not say much more: only two things. First, increasing the pipeline of medics by creating more psychiatric foundation training places with direct experience of eating disorders would help and, secondly, better resourcing eating disorder services would allow workloads to be managed better and stop people leaving as they are overworked and carrying risks that are too high.
Those risks are exacerbated by dangerously low in-patient capacity. As some Members of the House will know, 19,000 people needed hospitalisation in England last year for eating disorders. That figure has doubled in 10 years but no extra beds have been provided. There are only 649 beds in England. That means that patients with BMIs of under 12 are sent to units while they wait for hospital beds to become available and that patients, who are often children, are sent hundreds of miles away from their families for months on end. When our daughter needed specialist in-patient care there were no beds available anywhere in the country. She was kept alive by the local hospital for a month until a bed became available 144 miles away. She received excellent care, for which I am truly grateful, but I am in no doubt that the distances that people have to suffer at these very difficult times often make it an unbearable situation.
What makes it, frankly, shocking is that commissioning decisions about how many beds and services we have are being made without the NHS having even basic data on the number of people suffering from eating disorders in the UK. You cannot manage what you do not measure. I call on the Government to institute a review of eating disorder services, informed by accurate prevalence data.
While there is much more to do to improve the lives of sufferers of these diseases, there is much to be thankful for: the staff who care and battle on despite the workforce shortages and resource limitations; voluntary organisations, such as Beat and TasteLife; the families and carers who may rage in private but refuse to give up on their loved ones; campaigners, such as Hope Virgo and others, who use their lived experiences to offer much-needed hope of a better tomorrow; and—if I may say so—the Minister, whose willingness to listen is genuinely appreciated.
With the help of this Government, we can take the actions necessary to improve the lives of people suffering from these dreadfully cruel diseases. They deserve nothing less.
My Lords, I congratulate the noble Baroness, Lady Parminter, on having secured this debate and introducing it so ably.
I start, somewhat improbably, in China—a part of the world currently in the news for reasons other than what I want to talk about. Only some four decades ago, 40 million people starved to death in the country during Mao’s rule; far greater numbers suffered from pronounced malnutrition. Switch to the present and things look very different indeed. Some 800 million people have been brought out of poverty over that period. Huge urban centres—several far larger than London—have emerged where there was once barren countryside.
I do not know whether noble Lords saw the TV programme on Shenzhen the other night. It was amazing—40 years ago nothing was there but green fields and a river; now, it is a massive high-tech centre, outstripping Silicon Valley. As noble Lords will learn in a moment, I am not in the wrong debate. Nothing like this has ever been accomplished before. Yet not all such change is positive. Some 30% of the population in China today—300 million people—are overweight or obese. An estimated 50 million still suffer from food deprivation, but now as a result of anorexia. A whole spectrum of online “vomit bars” has sprung up in which people encourage each other to vomit after eating.
As China goes, so goes much of the rest the globe. The number of people either overweight or obese in the world now surpasses those who live at near-starvation levels—an amazing, but not wholly positive, turnaround. What a reversal of history this is, and, totally unlike in the past, the vast majority of obese people are not the rich but those in lower income groups. The poor used to be the ones who were undernourished or starved to death. Today, in complete contrast to starvation in the past, anorexia across the world is mostly a pathology of the more affluent.
All this may seem a bit remote from the Question posed by the noble Baroness, Lady Parminter, and indeed from the UK. However, I see it as an essential backdrop. It shows the sheer scale of the issues involved, based on a sort of global reversal of traditional diets and eating habits. It was good to see Health Secretary Matt Hancock taking a similarly macroscopic view in a speech to a recent conference on eating disorders.
The term “eating disorder” is usually reserved for those suffering from anorexia and/or bulimia. Yet the only genetic factor involved in these conditions is dispositional, not causative, which is exactly the same in the case of obesity. The health implications are far-reaching indeed. Two-thirds of adults in the UK are classified as overweight or obese, with a full third in the second of these categories. Anorexia and obesity used to be thought of as two distinct populations; to some degree this is true, since the former is more often linked to high levels of distress and malfunction. However, the incidence of anorexia is much lower. Recent research indicates that those at the more extreme levels of obesity show comparable levels of anxiety, stress and depression to those with anorexia, particularly in the case of female sufferers.
I welcome the Government’s initiatives for raising consciousness in schools about eating disorders and their parallel reforms to provide early treatment within the NHS. More than one report in the Commons has warned about the serious lack of training on eating disorders for doctors. Just as important is ensuring that GPs are up to date with the most recent research in a field that has a strong medical pathology yet is closely embedded in lifestyle.
Since the Minister has strong Oxford connections—and speaking as an academic myself—I should like to ask her views on the avant-garde research into anorectic disorders being carried out by the Department of Psychiatry at Oxford University. The interest of this work is the attempt to link the biological, emotional and somatic processes involved in anorexia. There is a shortage of evidence-based treatments for anorexia and eating disorders more generally. The Oxford Centre for Human Brain Activity—a really interesting research organisation—is working together with psychiatrists and social scientists on this.
We need further long-term studies of eating disorders, in the wide sense in which I am using the term. A study carried out at Harvard University showed that fewer than half of adults in the US achieve recovery from anorexia or bulimia nervosa over the long term. It is good to see that this research explores the links between those apparent opposites—anorexia and obesity—which I am saying are part of a connected syndrome. The common link is a compulsive relationship to food coupled with distorted but powerful body imagery. Some of the underlying neural mechanisms seem to be the same. One piece of research in the US describes anorexia and obesity as—going back to Chinese—the yin and yang of bodily weight control.
“Go on a diet!” That is the common-sense response to obesity. However, both anorexia and obesity stem from the fact that we live in a world where we are all on a diet. For the first time in history, an almost endless array of foods is available on a daily basis. Every day, consciously or not, we have to decide what to eat in relation to how to be. Even noble Lords have to take these decisions since there are so many cafés on site here; I never quite know which one to go to at a particular time.
I have a couple of questions for the Minister in concluding, as one is supposed to. First, what procedures have the Government established to track and assimilate cutting-edge research on the diagnosis and treatment of eating disorders? By that I mean international research, not simply research in this country; as I am trying to stress, this is an amazing global reversal in human beings’ relationship to food and the body, so the research needs to be transnational. Secondly, and in conclusion, will the UK follow the lead of other countries in recognising the need to explore the aetiological parallels between anorexia and obesity?
My Lords, I cannot claim to be an expert on the subject of this very important debate, for which we are indebted to the noble Baroness, Lady Parminter, who has done so much to help make known the extent of the suffering associated with eating disorders and involved herself so fully in the work of bringing relief to those who suffer, while promoting greater understanding of the causes of this deeply distressing condition.
My participation in this debate stems from my admiration for all that is being done by our remarkable health professionals—often in difficult circumstances, as we have heard from the noble Baroness—and by so many members of staff in our country’s schools to help those afflicted by eating disorders. It is on education that I will concentrate, drawing on the work and great experience of my friend and close colleague, Neil Roskilly, chief executive of the Independent Schools Association, a body that represents the interests of some 550 smaller independent schools, and of which I am president. Our member schools are increasingly sensitive to the needs of children who develop eating disorders or are at risk of doing so. Forming small, closely knit communities, they are only too ready to share the expertise that they are accumulating with state schools in the spirit of partnership that increasingly characterises the relationship between the two sectors of education. The more closely that they can be drawn together, the more our country will gain.
Schools in many parts of the country can now benefit from the excellent work being done by the charity Beat, which was mentioned by the noble Baroness, Lady Parminter, and with which she is closely associated. It is making a major contribution, particularly through its expanding programme of training for schools, and is keen to do more. I shall return to it later in my remarks.
Schools are inevitably in the front line where eating disorders are concerned. Teachers and others in the school community, including of course catering staff, occupy a key position. They can spot the warning signs and so secure early recognition and intervention, which are vital if young people are to gain access to the expert support that they need in the early stages of their difficulties. As we all know, eating disorders are ultimately not about food; rather, they are symptoms of underlying mental health needs that, through training the key people, can be recognised and addressed, so the resources must be adequate to provide the essential training in schools.
Public discussion and debate are essential too in helping sufferers overcome the shame and the need for secrecy that they often feel. Weight loss is only one of the possible symptoms. No less important can be indicators such as mood and behaviour. Irritability, restlessness and difficulty in concentrating in class can all too easily be explained away if school staff have not received the training that is needed to probe the real difficulties successfully, so equipping school staff with the skills to encourage children in the most sensitive way to talk openly about their feelings must be a central part of any training.
It is so very important to combat the stigma that still attaches to eating disorders, the stigma that treats them as a sign of vanity or a means of gaining attention. The Government’s recognition that more needs to be done in training schools to banish stigma and identify the early signs of trouble is to be warmly welcomed. The funding announced last year for the national mental health programme, working with the NHS, is an important start, although the target of training a senior member of staff to lead on mental health issues in all schools over the next four years is not perhaps as ambitious as many hoped.
More thought needs to be given to the long-term improvement of clinical referral services for children. With more teachers trained to lead on mental health issues in schools, demand for early access to expert NHS clinical support will increase. At the moment services vary far too much in quality and extent across the country. Instances of children being turned away by the NHS because their condition has not become life-threatening are a cause for grave concern.
A mentally ill child faces an almost insurmountable barrier to learning. In view of the need for early intervention, and the large potential cost to the NHS and families of the growing number of severe cases, the vital work of charities such as Beat in schools should be recognised and supported.
Working in co-operation and in partnership with the Government, charities can help achieve the progress we all want to see accomplished. Beat’s Spotting the Signs training for schools is now available widely in the north and in some other parts of our country. It will be extended as further resources allow. Beat is also working with organisations such as the Independent Schools Association, which I mentioned at the outset, to make more teachers aware that a child’s mental health is just as important as their physical health. That surely is an absolutely fundamental point.
It is in schools that part—a significant part—of the answer to the urgent problems at the centre of this important debate can be found. I end by thanking the noble Baroness, Lady Parminter, again for initiating it.
My Lords, I will speak a bit more about workforce issues in this very important debate. As the noble Baroness, Lady Parminter, mentioned, nearly one in seven consultant posts in this specialty in England is vacant. I think this reflects the state of the psychiatry workforce across all of its subspecialties. In 2019, the Royal College of Psychiatrists found that around one in 10 consultant psychiatrist posts in England were unfilled. These “missing” psychiatrists in our NHS have an obvious and detrimental effect on patient care in eating disorders and across the rest of psychiatry too.
This also has a secondary and confounding effect on the psychiatric profession itself. A report this year by the BMA found that more than three in five mental health professionals worked in teams with gaps in the rota and that more than half reported feeling too busy to provide the care they wanted to on the last shift they worked. No wonder psychiatry has perennial recruitment problems. I will share an interesting statistic. Of 74 medical subspecialties, 50 are more competitive than general psychiatry and 72 are more competitive than my specialty of the psychiatry of learning disability.
The shortfall in psychiatrists cannot be resolved without addressing the ongoing underresourcing and understaffing of mental health services, especially when people’s lives are at stake. The noble Baroness, Lady Parminter, made a very important point about the high mortality rate in eating disorders compared with, for example, schizophrenia, which people think of as a serious psychiatric disorder. Reversing the workforce shortfall requires a joined-up and concerted effort. Could the Minister comment on the Government’s current plan to improve the recruitment and retention of psychiatrists?
Doctors will choose psychiatry when they feel that mental health is given the same priority and concern as physical health. Although that is now policy, mental health care is still treated as physical health’s poor cousin. In 2019, the OECD estimated that mental ill-health costs the UK £94 billion a year. Contrast this with the £2.3 billion extra pledged by this Government for mental health by 2023-24. It is clear that more needs to be done now; the human and economic costs are far too high. Can the Minister advise the House on what steps the Government are taking to address the shortfall in spending on mental health?
It is not just the medical workforce which has suffered over the last 10 years. Since 2009, the mental health workforce has also lost 7,000 nurses and 6,000 clinical support staff, and more than one in 10 clinical psychology posts is vacant. The sorry state of the workforce is only one part of the story. The noble Baroness, Lady Parminter, emphasised that early intervention is key to success in the treatment of eating disorders and spoke clearly about the need to introduce waiting-list standards for adult services. However, early identification of eating disorders has to happen before anybody can intervene. That means that all doctors need basic knowledge about how to recognise them. The noble Baroness notes that one in five UK medical schools seems to teach very little about eating disorders, although I understand that the GMC has specified that all medical schools should teach this. It is crucial that staff across the health service, including in primary care and general hospitals, have a basic working knowledge of eating disorders and other common mental health presentations. It is not something to leave just to specialists in psychiatric services.
On 10 February, I will be asking the Minister about the Government’s plans for mandatory training for health and social care staff in learning disability and autism. There is a relationship between eating disorders and learning disability and autism. As many as 90% of children diagnosed with autism have some form of disordered eating, and some estimates suggest that up to one in five women with anorexia has autism. The situation is complex when multiple mental health conditions coincide; there is no substitute for better trained and supervised staff.
There are many possible responses to the issue of training. The House of Commons Public Administration and Constitutional Affairs Committee recommended last year that all newly qualified doctors should work in psychiatry in one of their six foundation placements and gain some experience of eating disorders. This request has been made many times before by the Royal College of Psychiatrists and others, including when I was president earlier this century. The Government’s response to the committee’s recommendations in August 2019 stated that
“the GMC will host a roundtable with HEE, NHS England and NHS Improvement, key bodies within the Devolved Administrations, the AoMRC and individual royal colleges, the Medical Schools Council and other key bodies.”
Could the Minister provide an update on the status of these discussions?
I will end by commenting on the importance of generalism. A suggestion is gaining ground that all subspecialists should be generalists as well, with the aim of minimising the gaps that can arise between specialisms—whether the specialism is eating disorders, learning disabilities, autism or anything else. Is it time to consider additional postgraduate qualifications for generalists, while ensuring that all general psychiatrists have training in these conditions?
I congratulate the noble Baroness, Lady Parminter, on securing this important debate, on speaking so frankly, honestly and powerfully about the subject, and on allowing me to speak about some broader, related issues in the mental health workforce.
My Lords, I too am grateful to my noble friend Lady Parminter for the debate today. I will speak particularly about anorexia, a killer disease that frequently affects young girls and women between 14 and 25. That is the area I have had most experience of, although, as other noble Lords have said, anorexia also affects adults.
As other noble Lords have said, anorexia has the highest mortality rate of any psychiatric disorder. The death rate associated with anorexia nervosa is 12 times higher than the rate for all other causes of death for females aged 15 to 24. Yet, as other noble Lords have said, there is much to be grateful for in that there can be a recovery, with enough support and treatment. Research suggests that 46% of anorexia patients fully recover, 33% improve and 20% suffer chronically. I am grateful that my daughter was one of the 46% who recovered.
According to Beat, the eating disorders charity, the average duration of the illness is eight years, but it can become severe and enduring, lasting for many years and having a hugely debilitating effect on the sufferer and their family. Thinking about people at the younger end of that age group, we know that the teenage period is a time of such emotional development as well as physical growth. It is a time of intellectual development and moving into the adult world. For sufferers of anorexia, isolated not only in their body but socially, the illness brings this growth and development to a halt. Cognitive development at this age is of huge importance, as it is often much more difficult to catch up afterwards, even if there is a full recovery. Eight years is the average time it takes to recover. Eight years in the life of a 14 year-old is a lifetime, and a huge loss of a key period in anyone's life.
The disease is sometimes considered not so much a disease as a life choice. There is perhaps a lack of awareness that the obsession with weight and body is so compulsive; that there is an overwhelming fear of gaining weight, and a distorted body image. Sufferers will do anything to get thinner, and the thinner they get, the more they think they need to become even thinner.
Sufferers also change personality. If somebody in your house is suffering from anorexia, you will find that your cheerful, open teenager can become aggressive, abusive, deceitful and manipulative, and an expert in inflicting pain on their loved ones. It is very hard for anyone who has not had first-hand experience of this debilitating and vicious disease to imagine what it is like to have to keep up surveillance and constant care just to keep your precious child alive. It is a deadly disease but, as the noble Lord, Lord Lexden, said, it is often seen as an extension of vanity—the obsession with image and appearance. It is far more complex than that, as other noble Lords have said in the debate.
It is alarming that the January NHS figures show that hospital admissions for eating disorders have risen by 37% across all age groups in the last two years. Hospital admissions are only for those who have to be prevented from starving themselves to death, so this is just the tip of the iceberg. It is a huge issue, and sufferers need intensive support and early intervention. As other noble Lords have said, the sooner they get the treatment they need, the more likely they are to make a full recovery. Prompt access to high-quality treatment and support can prevent people getting to the point where hospital admission is the only course of action that will keep them alive.
I agree with what has already been said: research has been starved of funding. My experience was quite some time ago, but there was very much a feeling that this was not really an illness but the teenage behaviour of adolescent girls, and a failure to recognise the results that could occur when people did not get the care that they needed.
I was interested to hear that research has proposed the idea that there may be a hereditary aspect, for example, and also that people are now looking into a metabolic dimension. As has been said, the relation to obesity is something that appears to be being looked into more. Certain individuals may be much more likely to suffer from anorexia when they experience stress, bullying or very severe pressure. I feel that we need to raise awareness of this as a disease that kills people, not a lifestyle choice, affectation or folly of teenage girls.
I hope that treatment and support will be made available consistently across the country. Whether you survive this disease should not be a matter for a postcode lottery. In my opinion, eating disorders have for many years been a Cinderella service within mental health, which is itself a Cinderella service. I hope, from the information we have had, that the Minister will reassure us that this will not continue to be the case. If not, there will be more and more tragic and unnecessary deaths, as sufferers’ lives continue to be at risk. Again, families and carers live with that risk of death every day. I hope that we are to get assurances from the Minister, as more and more families will be torn apart if there is not very prompt and urgent action to provide support and treatment for people suffering from all eating disorders. However, I make a special plea for anorexia.
My Lords, I too am extremely grateful to the noble Baroness, Lady Parminter, for securing this debate, for the great knowledge she has on the topic and for the great campaigning she has done. I am also grateful to the group that she accompanied last week, when we met the head of Public Health England to talk about this issue and some others. We were pressing PHE to perhaps review its approach.
I am also grateful to others who have contributed to this quality debate, and to my noble friend Lord Giddens. We once had a debate in his name on this topic. I looked it up today and way back on 25 February 2013, we identified some issues arising that needed addressing; here we are in 2020, with many of the same problems around. They may be on a bigger scale but call for similar solutions. Back in April 2013, I was one of those who helped create the All-Party Parliamentary Group on Obesity. We had not had one before but it got off the ground then. Look at what has happened between 2013 and 2020: on almost every count, obesity is now worse. There are very few areas in which we can point to progress.
I was at the London School of Economics last night—my noble friend Lord Giddens has strong past connections with it, as he was the head of the LSE. I was there to listen to an address by Professor Richard Layard—my noble friend Lord Layard, one of our colleagues. He was speaking on the publication of his latest book, which is on the topic of happiness. That relates directly to what we are debating this evening. What are we about with health? We seek a better life and happiness. My noble friend has done much work in this area in the past, particularly on mental health, and was closely associated with the introduction of talking therapies under the Blair Government. I think over 20,000 new staff came in to work especially in that area; it was not enough, but it was a major change. We now find many people complaining of having to wait too long before they get assistance on talking therapies, while the length of many courses on talking therapies has been reduced to a point where their impact is perhaps not quite so significant as previously.
I will not repeat all the points that my friend, the noble Baroness, Lady Hollins, made but we have a grave shortage, right across the board. We have shortages in addiction generally; in psychiatrists; in doctors, nurses and staff at many levels right across the mental health field. We look forward to having some comforting response, I am sure, from the Minister on how we are going to see improvements in those areas. They are sorely needed because we seem to have a shift from physical health into mental health, and the caseload is growing all the time.
I spent many years working on addictive issues. I have a personal history of problems with alcohol and drugs. I was on my knees and had to find a way forward, and I did that nearly 40 years ago. Since then, I have spent much of my life working with people with addictions—not just in alcohol and drugs but food, too, and at both ends of the spectrum with food. My dismay is that we have a divide between the approach on obesity and that often taken on eating disorders, when in fact there is so much commonality between them. As others have said, it is time that we started trying to bring some of these elements together, and to work closely in a more overarching way than in the past.
I am pleased that the Government have announced that they are to introduce a cross-departmental approach on a number of addictive issues. Can the Minister say why the subject we are talking about and obesity have not, so far as I can see, been specifically included? They are not being addressed within that approach. When will the work get under way? Can she give us a little more information about its timescale and who will be involved with it? What does she expect to come out from the new review that is being established? But overall, I welcome that development.
Having examined some different types of addiction, my experience is that in many areas they seem to have common themes running through them. Look at how we address it within Public Health England; it is interesting that it has separate units dealing with drugs, alcohol and the problems arising with food. We should look at the structures within that major organisation to see whether it is properly set up for prevention, given that the Government have now decided that they need a cross-departmental approach on reviewing addiction.
It is not easy to find solutions, particularly on anorexia. Among the addictions I have looked at, it is one that hits quickly and is very difficult to reverse. It also has quite dramatic impacts on families, relatives and other people around them. In looking for solutions we should not limit ourselves to dealing with the individual; families should be involved, too. We should look to have the widest possible participation, not just from professionals—we are short of them and need more—but more across the voluntary sectors. We should look at what alternatives may be available.
I am quite open in saying that I believe that there is a requirement for a spiritual approach. That is not something that we frequently talk about in the Chamber, but I have certainly seen many people whose lives have been written off yet who have found by one means or another, using the 12-step recovery programme, their way to a better, fruitful life. I am pleased to report that, in March, we will set up for the first time an all-party parliamentary group on this topic. The inaugural meeting will look at the 12-step recovery programme on addictions to see how it might be applied over the widest possible area to help people who have problems which seem difficult to resolve and who may find an answer in it. I would like to hear whether the Minister welcomes that development.
My Lords, I think that it was Walling Simpson who famously said that you cannot be too rich or too thin. We never in this House debate being too rich, but we occasionally debate the problems of those who aspire to be too thin. Walling Simpson, famously, ate almost nothing and was probably mildly anorexic.
The noble Baroness, Lady Parminter, has outlined the terrible situation that families find themselves in when they have a child or young person suffering from this terrible disorder, whether or not it is anorexia nervosa, obesity or bulimia—bulimia in particular is very difficult to treat, as is anorexia.
While I was driving down from Norfolk this morning, I listened to an excellent edition of “Woman’s Hour”, on which a young woman called Hannah described her own anorexia and how it felt to her. She had been waiting for treatment in the Greater Manchester area for 18 months, and she was offered just one of a group of services that were available in the area, with no thought as to whether it was appropriate for her. Even then, it was a great time coming. Dr Agnes Ayton, chair of the eating disorders faculty at the Royal College of Psychiatrists, made many of the points, brilliantly and articulately, about the difficulties that people have in accessing services, saying that while we have invested in young people’s and children’s services through child and adolescent mental health services, we have left young adults far behind in their ability to gain access.
Having re-read the debate instigated by the noble Lord, Lord Giddens, back in 2013, it strikes me that we have repeated this evening exactly what was said during that debate: that there has been very little improvement—and, of course, the numbers have gone up. As to why the numbers have gone up, the noble Lord’s own specialty has told us: they have perhaps been rising since the 1960s. We are very keen to say that it is not a lifestyle choice, but it is lifestyle factors that have made people want to go down this route in the first place. Biological triggers turn a normal seeking of a slim, elegant, beautiful figure into something much more pathological. That is the thing that we really do not understand.
As the noble Baroness, Lady Parminter, said, the report by the NHS ombudsman on how patients are failed was truly shocking. Since then, we have had much better guidance in commissioning, but those documents are often ambitious, noble but pie in the sky and are not widely taken up, for all the reasons which have been articulated. Eating disorders are more common than people realise. Some 80% of people who have them never go to a doctor, and many episodes are managed in families with no access to specialist services. Such services may not be needed, because, within a few weeks or months, the child or young woman has tackled the disorder themselves and has been able to get to grips with what has become a pathological desire to be thin without flipping over into something that does not get better. It is important to remember that, because those who are referred are therefore often in great need of specialist care, and that is the thing that is so difficult.
Eating disorders are of course prevalent in young men as well, particularly those with a gender disorder of some kind or who are troubled by their sexuality. I have treated at least two young men with anorexia nervosa and found them quite as difficult as young women to reach and help through their disorder. It is also common—and getting commoner—in older people. My Aunt Florence never recovered, and died when she was in her 90s. She was slim, but healthily so, all her life until she was in her 80s, when she started to adopt strategies identical to those of a much younger woman. This was similarly pathological, and she starved herself almost to death. Elderly people who get these disorders are often inappropriately investigated, because of the link between physical ill-health in old age and loss of appetite. Perhaps “inappropriately investigated” is not fair, but these things are much commoner in later life than one might imagine.
We have had the commissioning help after the ombudsman’s report and we got the extra £30 million put into young people’s services, but it has simply not touched adult services. Other noble Lords have already mentioned the mortality rate, so I will not stress that.
Historically, such disorders were a lot commoner than we think. There is a description of an illness suffered by Mary Queen of Scots which is a classic eating disorder. There are explicit medical descriptions from about 1670. In the 19th century an awful lot of young women had a condition called chlorosis. People turned slightly green because they had iron deficiency, but it is also thought that this was largely caused by anorexia. There were pressures on young women then which they too addressed in that way.
Treatment is extremely difficult. Evidence-based treatments are few and far between. What we try to do is keep people alive and at a healthy weight long enough for them to get a grip on it and recover for themselves. That is true not just for anorexia nervosa but for many other mental health disorders, for which we do not have the specific treatments we have for psychoses. People need a lot of help, support and psychotherapeutic approaches. The ones that are good for some people may not be for others. The commissioning document makes it clear how important it is for people to be given choices.
My time is up. I stress that we need more investment in a choice of services which are readily accessible for people locally, so that they do not have to just accept what their local service provides. That is the major thing the Government should be doing. What are they intending to do?
My Lords, I too offer my thanks to my noble friend Lady Parminter for securing this important debate. For many years, this has been an invisible disease without enough resources to ensure that those who present to doctors get the vital support that they need immediately. I pay tribute to my noble friend for her tireless work on eating disorders, based on her own family’s experience. I also pay tribute to my noble friend Lady Janke for speaking of her family experience. My noble friend Lady Parminter talked about the lived experience of sufferers who are champions but my noble friends both showed, through their contributions, the effort it takes to hold a family together while supporting a child going through this terrible disease. I remember a friend of mine disappearing from school some 50 years ago at the age of 14 and never returning to mainstream school. Until I met her sister, some 30 years later, we never knew that she had had anorexia. It was not spoken about and there was hardly any treatment at all.
It is important to recognise that support and treatment have improved substantially in recent years, including the extra £30 million for young people with eating disorders, but it is clear from this debate that the context of resources is vital. Clinical approaches to eating disorders have changed, but the number of patients and the support they need is at crisis point. We have heard that in 2018-19 there were more than 19,000 patients admitted to hospital with eating disorders but only 649 beds in England. That is an astonishing two patients per hour per day, yet we know that resources are so scarce that patients are now routinely turned away for not being sick enough.
The noble Baroness, Lady Murphy, spoke about Hannah on “Woman’s Hour” today. I suspect it was the same Hannah whom the Sunday Times talked to last Sunday; she was turned away from the Greater Manchester Mental Health NHS Foundation Trust because she was not ill enough and her BMI had not dropped to the point at which it would automatically guarantee entrance, even though in her experience of the disease there was evidence that she was deteriorating rapidly. She is very brave in speaking up. We need to know the reality of what is happening. I am afraid that one of the reasons for this—other noble Lords have been discreet, but I will not be—is that clinicians are having to ration support for eating disorders. The parity of esteem enshrined in legislation under the coalition is still a pipe dream.
A further problem is touched on in some of the helpful briefing we have had, including that from the GMC and the Library: the transition of young people from CAMHS to adult services. In my family’s experience of CAMHS—everyone should recognise that there is usually some experience of mental health services—the transition period was a complete nightmare, even though we got an extra year after the age of 18 to transition through. The attitude and approach were completely different and led to a crisis within a year. That problem of transition, which has been recognised and understood in education and children’s services for the most vulnerable young people who are looked after or have learning disabilities, also needs to be applied to children with mental health problems, particularly those with eating disorders since we know that this disease targets those aged between 15 and 25. To suddenly change everything at 18 is an extremely traumatic experience for the young people and their families. What plans are there to extend access to children and young people’s mental health services up to the age of 25, obviously transitioning as is best for the individual concerned?
While the Government discuss abolishing the four-hour accident and emergency targets overall, what plans are there to introduce waiting time targets for adults as well as children in accessing mental health services, and specifically for eating disorders? Currently only a third of young people with diagnosable conditions get NHS treatment without long delays. Liberal Democrats believe that we should ensure that 50% of children and young people with diagnosable conditions should have treatment by the end of this year, improving to 100% by 2025. Currently, only four in 10 adults get access to treatment. We believe that seven in 10 adults should get access to treatment by 2022. We must set an ambition that everyone who needs treatment gets it by 2025. That will be the point at which we can believe that we have parity of esteem in mental health services.
Other noble Lords have spoken about the importance of early diagnosis. Currently, medical students receive on average less than two hours’ teaching on eating disorders throughout their undergraduate training. By improving training, we will be able greatly to improve early intervention, especially for those on the front line—GPs and more general physicians. Other noble Lords, including the noble Baroness, Lady Hollins, have spoken with experience and expertise on this.
There are other workforce issues. The helpful briefing from the GMC pointed out that there are only 70 posts, mainly in CAMHS, of which a substantial number are vacant. Both the noble Baroness, Lady Hollins, and the noble Lord, Lord Brooke, talked about the practicalities of gaps in the rota, which inevitably impact on patient care. How on earth can you attract young medics to psychiatry if candidates know that resources are not just scarce but will rely on them turning away those patients they know need urgent intervention?
The noble Lord, Lord Lexden, spoke about the importance of educating school staff in recognising the difficulties that some young people face and in helping to signpost them to their families to get help. I too pay tribute to Beat and other charities that provide that expertise to those who can help. However, above all, it is the patients and their families who need help and support. We are overcoming the burden of secrecy in eating disorders, which is good, and the voice of Hannah and many others who have a lived experience of eating disorders is vital. However, we also have a duty to provide the resources for beds, access to clinics, staff and support staff to help people overcome this disease. None of that can happen without money. Therefore, my final question to the Minister is to ask about the increase of funding for adult services and treatment of eating disorders more generally in this area over the next five years.
My Lords, I congratulate the noble Baroness, Lady Parminter, on securing this debate and on her moving opening remarks, as well as all other noble Lords who have participated in the debate today on this important and growing challenge.
As we have heard today, eating disorders are complex mental illnesses. I absolutely agree with my noble friend Lord Brooke that we need to see progress. I spent a few minutes looking on my iPad to see whether I had answered the debate in 2013 from this Dispatch Box. I am sure that I would have remembered if I had, and indeed, I did not—one of my colleagues dealt with that issue. But it is remarkable that that debate very much reflected the things that have been said this evening, and it is a bit depressing that we still need to make some progress today.
The thing about eating disorders is that you can develop one no matter your age, gender or background. Some examples of eating disorders have been mentioned: bulimia, binge eating, anorexia and obesity. There is no single cause of this, as noble Lords have said; it can be very complex, and people might not have all the symptoms for any one eating disorder. I echo the thanks expressed by other noble Lords to the General Medical Council and Beat in particular for their information about this matter.
The General Medical Council noted at one of the round tables that it organised on this in November 2019 that there is a lack of eating disorder specialists in the UK. There are only 70 posts, mostly in child and adolescent mental health, with some in adult, and approximately 15% of posts are vacant. Coupled with the lack of beds and the stories that noble Lords have recounted, that makes this situation very serious indeed.
We know that there is an important link between obesity, mental health and eating disorders. My noble friend Lord Giddens definitely expressed this eloquently and in greater depth, but this relationship is often neglected. Awareness of this is neglected as well, as several noble Lords said. Medical training across the board does not adequately recognise the seriousness of this condition.
I think we all welcome that the NHS long-term plan and related initiatives which emphasise mental health provide a unique opportunity to make progress on improvements to eating disorder services and the relationship with education and training. For example, I am pleased to hear that the General Medical Council is now working with the Faculty of Eating Disorders Psychiatry and other key stakeholders. That is some comfort, but I was very disturbed by the contribution by the noble Baroness, Lady Hollins, when she addressed the workforce situation; she posed some serious questions to the Minister.
In December 2017, the Parliamentary and Health Service Ombudsman published Ignoring the Alarms: How NHS Eating Disorder Services are Failing Patients. The report made five recommendations for improvements in NHS eating disorder services. Indeed, the Public Accounts Committee went on to say that this was important and needed to be acted on. We all know, as noble Lords have said, that collaboration is needed at both service level—as the PHSO report highlighted in terms of, for example, handover and continuity of care—and at system-wide level with regulators, commissioners and others working jointly to identify and implement improvements. The PHSO also recommended a public health campaign, which would help to raise awareness of the impact of this condition. Is that likely to happen?
Noble Lords will know that a Guardian investigation established that coroners in England and Wales have served a prevention of future deaths notice in at least 12 cases, identifying problems that have been mentioned tonight, including a lack of staff or beds. Coroners were so alarmed by these failings that they sent official warnings to 11 trusts that provided care for people with anorexia and bulimia between 2013 and 2019. Grace Freeman, a policy and campaigns officer for the mental health charity Mind, said that the cases were a
“shocking reminder of the poor quality of care too many young people receive from mental health services, particularly those living with eating disorders.”
The noble Baroness, Lady Parminter, made a plea, saying that science and research needs investment to provide the evidence base that the Government want, to make sure that eating disorders are dealt with with the seriousness they deserve. For example, there is no official data on deaths due to eating disorders; at a recent inquest, a doctor said cases were not being properly recorded by the NHS. As we know, suicide is one of the biggest risk factors for people with the condition, with between one-fifth and one-third of patients taking their own lives.
As far as I, aged 67, can see, if I develop an eating disorder, it depends on where I live but I would not be eligible for treatment in one of the 49 adult eating disorder clinics in England and Wales. According to an investigation by the “Victoria Derbyshire” programme, three have a cut-off age of 65, with older patients referred to general geriatric mental health units, which are likely to be unable to provide the same level of tailored care as would be required.
Finally, I agree with the noble Baroness, Lady Brinton, that it is awful that our clinicians face rationing treatment for eating disorders. It is completely unacceptable. This condition requires more investment, more choice and more money being available to combat it.
My Lords, I thank noble Lords for their expert contributions. In particular, I thank the noble Baroness, Lady Parminter, for securing what has been a significant debate, and those noble Lords who spoke of their lived experience tonight. That is brave and an important contribution, both to inform policy and to let people outside this place know that there should be no stigma in speaking up. I wish to thank each and every noble Lord who has contributed tonight.
We know that eating disorders can be utterly devastating for the people suffering from these conditions and for those around them, including their families and friends. We know that they are not an aspect of vanity, as the noble Baroness, Lady Janke, said, but serious, life-threatening conditions with some of the highest mortality rates of any mental health disorder. They can have severe psychological, physical and social consequences—sometimes for a lifetime—and are more prevalent in young people but can occur at any time in life and in someone from any background. That is why we want to ensure that people have access to the right mental health support in the right place at the right time. We know that we have more work to do to ensure that we get there.
Improving eating disorder treatment services is a key priority for the Government; it is a vital part of our work on improving mental health services. As the noble Baroness, Lady Janke, rightly said, we know that the earlier an intervention is made and treatment provided, the greater the chance of recovery. That is why the Government set up the first standards to improve access to eating disorder services for children and young people, which will ensure that by 2020-21, 95% of children with an eating disorder will receive treatment within one week for urgent cases and within four weeks for non-urgent cases. We are on track to meet that commitment.
As raised first by the noble Baroness, Lady Parminter, and subsequently by others, in-patient treatment is also important, although we want it to be a last resort. That is why in 2014 we announced that we would invest £150 million to expand community-based care and why we are making good on that promise. It has resulted in 70 dedicated new or extended community services now either open or in development, which has led to faster access to eating disorder treatment in the community, with the number of children and young people accessing earlier treatment up from 5,234 in 2016-17 to 6,867 in 2017-18. The services are designed to give young people early access to services in their communities with properly trained teams. They include extended access to talking therapies, which, as the noble Lord, Lord Brooke, pointed out, are very important. In that way we can avoid extended hospital stays wherever possible.
Although eating disorders are commonly first experienced by people when they are young, conditions can continue into adulthood, as has been noted. Following the PHSO’s report, NHS England has convened a working group with NHS Improvement, Health Education England, the Department for Health and Social Care and other partners to address recommendations to take into account planning for improvements in adult eating disorder services.
As has been mentioned, there are currently 649 beds for treating eating disorders. We recognise that there is demand for extra beds, which is why we have developed a comprehensive activity dashboard—it is not very well named—which provides current and trend data regarding the use of in-patient services for adults with eating disorders. We shall use this to inform decisions regarding in-patient capacity requirements for local populations both in the short term and over the longer term to improve access.
In addition, for children and young people, the national accelerated bed programme for Child and Adolescent Mental Health Services is already supporting the delivery of care closer to home, and we hope that this is starting to improve the situation. Issues regarding geographical variation were raised by the noble Baronesses, Lady Murphy and Lady Thornton. We want to ensure that patients with eating disorders can receive treatment as close to home as possible. NHS England has recently created a review of NHS in-patient and community eating disorder services so that it can understand current provision, measure levels of geographic variation and allow the modelling of workforce implications to try to respond to those services.
I want to respond to the point raised by the noble Baronesses, Lady Hollins and Lady Brinton, as well as by others, regarding investment in mental health services. As I have already said, we have increased funding for eating disorder services, but we have also ensured that investment in mental health services must rise at a faster rate than in overall published funding. Each CCG must meet the mental health investment standard by which their 2018-19 investment in mental health rises, at a faster rate than the overall published programme of funding. CCG auditors will be required to validate their 2018-19 year-end position in meeting the mental health investment standard. In 2018-19, 100% of CCGs met that mental health investment standard. This is to ensure that we see an increase in the mental health investment standard, so that improvements can be made to access times, to the workforce and to all the other areas which have been referred to in the debate.
I would like to move on to the questions raised regarding access and waiting times for adult services. As the noble Baronesses, Lady Brinton and Lady Parminter, will know, we have brought in the eating disorder waiting time for children, but we are also trialling a four-week waiting time for adults and older people community mental health teams in local areas in order to understand how they should best be introduced. I understand the impatience for waiting time standards to be introduced immediately. Given the nature of our debate today, I ask for some understanding; we are building on a low base across the mental health system. We want to make sure that the waiting time standards we introduce are clinically appropriate, that the system is able to respond and that they are on track for delivery and sustained once brought in. I am happy to respond in a more detailed way subsequently if that is not a sufficient answer, but that is why we are bringing in the waiting time standards in that way.
On the question regarding transition that the noble Baroness, Lady Brinton, asked—rightly, given the questions identified across not only health but education and social care systems—two areas of the country with eating disorder services that are new care models, including West Yorkshire and Harrogate, are starting to make important progress in joining up young people’s and adults’ eating disorder services and improving the treatment and care received as close to home as possible. They are modelling services that, as we evaluate them, we hope could be rolled out in other parts of the country. I hope that answers the question of how we are trying to improve that.
On the question about workforce raised by a number of Peers—the noble Baronesses, Lady Thornton and Lady Hollins, and others—it is quite right that we recognise the need to recruit more mental health nurses and psychiatrists into the system. As was rightly said, there have historically been challenges in bringing in psychiatry trainees. We now have 300 more consultant psychiatrists than in 2010, so we are starting to make progress. We have focused on driving forward work to improve recruitment into psychiatry, working with the Royal College of Psychiatrists on its Choose Psychiatry campaign. To attract more junior doctors into psychiatry, the new junior doctor contract gives psychiatry trainees a £21,017 pay premium in addition to their normal pay. This is an additional £3,507 per annum for a typical six-year training programme. We also have additional support and similar additional payments in the nursing arena to attract nurses into specific specialties, because we recognise the need to do so.
In addition to this, questions were raised about prevalence. The important question was asked: how can we possibly make policy if we do not have up-to-date and accurate data on which to make that policy? As a data geek, I could not agree more. Therefore, while we have some useful data from the 2017 mental health of children and young people in England survey, which is helpful, we want to improve the information we have, so we have included—I am really sorry to use this acronym—the SCOFF eating disorder questionnaire in the 2019 health survey for England, due for publication in December 2020. We are working on securing a financial agreement for the next APMS in 2021. Content for the survey will be prioritised during the scoping phase, which I know will provide important prevalence data—something we want to see.
I have two final points regarding training and research funding, both of which are essential if we are to move forward. We certainly agree that mental health should be an integral part of medical education, and we thank the GMC for the work it has been doing to explain and illustrate by professional experience the principles of identification, self-management and referral of patients with mental health conditions. We are committed to providing the best training experience for all junior doctors. We will work with the GMC and relevant stakeholders to try to improve the training available. I know that the noble Baronesses, Lady Parminter and Lady Hollins, have been particularly involved in this. Perhaps we could take up this point afterwards.
When it comes to the questions of research raised in particular by the noble Lord, Lord Giddens, but also by the noble Lord, Lord Brooke, of course we need to understand these questions with much more granularity if we are to improve services, be more targeted with our policies and spend money more effectively. This year, we invested about £93.4 million in mental health research, which is up from last year. We are committed to having mental health research as a priority area. In particular, I was always very proud that the only biomedical research centre that focused on mental health was at Oxford Health. I was very proud to have opened that as the previous Mental Health Minister.
I am not aware of the specific research paper that the noble Lord, Lord Giddens, raised, but I am very happy to look it up after this debate and come back to him on it. When it comes to what I think he referred to as the ecological relationship between obesity and eating disorders, as a department we definitely consider that we must work very hard on making sure our prevention agenda works holistically across the entire addiction panoply. Indeed, we will be taking forward the prevention Green Paper in a way that ensures joined-up policy, not only in the department, but across government. I am very happy to follow up on the question regarding the 12-step approach.
I think I have touched on the majority of the commitments in the long-term plan, so I will not go into details because I have come to the end of my time, but I conclude by thanking all Members who contributed, in particular the noble Baroness, Lady Parminter. I hope I have reassured noble Lords about the Government’s commitment to improving eating disorder services, that we recognise the devastating impact of eating disorders and that we want to ensure that all those with eating disorders can access high-quality and vital mental health support much earlier, because we understand the impact this can have.
House adjourned at 8 pm.