Health: Mental Health Strategy
(13 years, 9 months ago)
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Baroness Murphy
To ask Her Majesty’s Government what plans they have to implement their new mental health strategy.
Baroness Murphy
My Lords, 10 days ago, the first ever cross-government mental health strategy was launched, laying out plans for the future of mental health care in England. I congratulate the Government on recognising the crucial fact that mental health affects every area of a person’s life and impacts upon their ability to play an active role in society and I welcome the Cabinet-level commitment expressed so far. The strategy also makes plain that mental health has a parity of esteem with physical health—a lovely phrase—finally giving the issue the equal footing it deserves.
Sticking with the good things for the moment, I am delighted with the commitment to repeal the outdated law which forces MPs to stand down if they have been sectioned under the Mental Health Act for more than six months. This is an important anti-stigma signal by the Government.
However, I turn now to my—what shall I call them?—not exactly anxieties or worries but a sense of unease about the messages. I had niggles about the New Horizons strategy from the previous Government, so I am not blaming the coalition; rather I am blaming all of us in government, professional organisations and the voluntary sector for letting the ball slip through our fingers. I declare a personal interest¸ having spent most of my career working in specialist psychiatric services with people with serious, life-changing mental health disorders such as dementia, schizophrenia and other major psychoses and serious disabling developmental disorders of personality.
For me, the overarching theme of the strategy represents a misguided, somewhat soft-headed, utopianism focused on well-being and mental good health, as though there were a direct connection between a happy society and reduction in serious mental illness. But there is not. Events and circumstances, often unavoidable, play a significant part in the origins of serious disorders—but only a part, and often a very small part.
Let me make it clear that the broader public health issue of mental well-being and the aim to intervene to prevent the experience of distress are legitimate national strategic objectives. The toll of emotional human misery and minor psychiatric morbidity costs England an estimated £105 billion every year. This burden spreads beyond health services to education, employers, the social security benefits system, housing, the criminal justice system, families and communities. National well-being should influence our approach to economics and it is entirely legitimate to try to intervene to promote good mental well-being. However, I have doubts as to whether this should be the target of a mental health document which will largely be read by health and social care providers.
Many in the Chamber today have campaigned for the wider availability of psychological therapies, but again I have doubts about what Marjorie Wallace at SANE has recently referred to as the “therapy for the nation” strategy, which comes across as a panacea for the whole spectrum of mental health conditions and is being launched against a background of active planning for cost improvements of about £20 billion in the NHS, with local authorities shamelessly slashing and burning community services.
The experience of many local voluntary organisations which work with people with serious mental disorders is that people are being turned away from help, especially from in-patient care, when they feel desperate or they and their families have reached crisis point. Mental health services are still not getting it right for people with serious mental ill health and I want a strategy that does. Only today I received a deeply moving letter from the mother of a young man with a chronic enduring psychotic illness whose life circumstances were extraordinarily tragic and who was receiving inadequate support from the community services.
I am particularly critical of the public health outcomes framework in the strategy document, which seems to me to be mostly aspirational wishful thinking. It includes everything from reducing reoffending and self harm, all the way through to access to green spaces and “improving social connectedness”—a Facebook account for all? It is all lovely stuff but nothing to do with mental ill-health realities.
We know from studies in the US and our own research that social interventions that make a difference—for example, to the mental well-being of children and young people—have to be comprehensive, very focused, usually costly and require major changes in the way services are organised. Successful pilot schemes have been exceptionally difficult to replicate on a larger scale and to translate from experience in the United States. It is a waste of time, as we have known from so many social interventions, to intervene with individuals and families on a small scale, yet there is a real danger that that is what we will do.
Let us take maternal depression as an example. I am not denying that there is some evidence for the efficacy of preventive interventions, such as home visiting, parenting programmes, peer support, the refocused Sure Start children’s centres, parent support advisers working with school staff, and other family support workers, such as health visitors and early years outreach workers. Your Lordships may have noticed that I have already mentioned an army of helpers and workers of one sort or another. Then there is the family-nurse partnership programme, which works with the most disadvantaged young families with complex, interlinked problems and is aimed at interrupting the transgenerational cycle of poor health. The evidence is poor that this will work unless it is properly replicated on a very wide and expensive scale. The Government have pledged to increase the health visitor workforce by a further 4,200 posts, refocusing health visitors on maternal and infant mental health. However, the overall evidence for the efficacy of health visitors has been slight in the past. The NICE report currently on its website is based on an earlier Health Development Agency review of the evidence, which did not give much comfort in this area. Research has been small scale; much of it is interesting and encouraging, but its findings have so far been modest. Yet we are about to embark on vast investment.
To support these and other programmes, the Department for Education has introduced a new early intervention grant, which will bring together funding for a number of intervention and preventive services. These will replace the current targeted grant. I have no quarrel at all with the idea of a general grant that local authorities can use for the priorities in their area, but altogether the early intervention grant will be 11 per cent lower than the aggregated funding for this year, with a further major drop for next year. What of the £400 million extra for psychological therapies, which can and should, in my view, be targeted on those with the greatest need? It is in the baseline funding of the NHS, but do we really expect that it will be spent in the suggested fashion in the context of the £20 billion reduction? Some of it will be retained by a few areas, but I have grave doubts that it will find its way through to where it is really needed.
I suggest that a mental health strategy should focus primarily on those with the most severe disorders, whose lives are so often wrecked by the misery of mental illness. It has to be fit to be translated into measurable outcomes for the commissioning board and turned easily into commissioning intentions by GP consortia. We know that GPs lack confidence in commissioning mental health services. A survey last year by the charity Rethink found that, although three-quarters of GPs are happy to take on responsibility for commissioning diabetes and asthma services, fewer than a third feel the same for mental health services. They know that they do not like what they get at the moment for their patients with severe mental illness. Only half of GPs are confident about the quality of specialist care for depression and only a third are confident about the quality of care offered to people with psychosis. Many GPs doubt that patients with mental ill health will get the treatment that NICE recommends. In a way, that should encourage us, because GPs will want change for the better. I know that the Mental Health Network of the NHS Confederation is doing some very good work in collaboration with the pathfinder consortia.
The well-being of the nation is an important thing, but it is perhaps something other than a mental health strategy, so does the Minister not have doubts about whether we know enough to intervene cost-effectively or whether we have the public wealth to intervene on a wide enough scale to make a real difference? Will he accept that the well-being of a nation does not have a great deal to do with the sorts of services that will be delivered to people with serious and enduring mental health problems? I should like to see a strategy that really gets it right for the seriously ill.
Finally, I look forward very much to hearing other noble Lords on this topic. I firmly expect them all to disagree with me profoundly and I hope by the end of this debate to be converted back to my usual optimistic self.
Lord De Mauley
I have been informed that at least one noble Lord has withdrawn his name from the list of speakers for this debate, which means that all speeches, except for that of the Minister, will be limited to six minutes.
Lord Newton of Braintree
My Lords, I had been going to say, “Five minutes not long”—six minutes still not long—“will speak a little staccato”. First, I declare an interest as chair of Suffolk Mental Health Partnership NHS Trust. Secondly, I shall make no special pleading on behalf of that trust; the points that I want to make are general points. Thirdly, I congratulate the noble Baroness, Lady Murphy, who has done us a service by getting this debate on the Floor of the House at what I think was short notice. I shall listen with great interest to the Minister’s reply to the thoughtful and penetrating points that she made.
I have a brief confession. I put my name down to speak, given the short notice, at only three minutes to 12, and I was slightly taken aback to find that I was second in the debate. It is just as well that I did not spend the whole weekend writing this speech, because I would probably have had to cut it in half. It is probably a mercy to the House that I have to be brief.
To start with, I congratulate the Government on having produced this paper. The very fact that it is there and seeks to put mental health into the mainstream in a different way is worth while. One cannot quarrel with its objectives. The list of specific objectives or policies in chapter 5 is pretty well impeccable, especially when taken with what the Government are saying about dementia. It includes services for veterans and, as the noble Lord, Lord Patel, will have noticed, services for drug misusers and offenders, which has been one of the Cinderella areas. All the right noises are being made, and I have no problem with the strategy. My concern—and this is perhaps a rather blunter way of putting some of the points made by the noble Baroness—is whether we have the right mechanisms for delivering the strategy on the ground. This is especially so in a time of austerity, and bearing in mind the demands for considerable savings of up to about £20 billion over a relatively short period, which actually started under the previous Government and which are now having an effect throughout the service.
There are two points. First, to echo something that the noble Baroness said, there is a clear link here between the worries in the voluntary sector, the third sector or the civil society—whatever it is being called this week—and the pressures on local authorities. That sector provides a wide range of services helping and supporting people, in both the mental health and the learning disabilities areas, as well as those with multiple problems including drugs and alcohol. There is a lot of concern about their prospects. Secondly, and most importantly, there is a real tension between some of the things being said and the emphasis on having not ring-fencing but local decision-making. I understand the aim but, whatever is said in this document, mental health remains, as someone in Suffolk said to me, somewhat below the radar with regard to public demand and perception. As it happens, I have never chaired an acute trust; I have chaired a specialist trust and two mental health trusts, so I have not faced this dilemma. But I am pretty clear that if I was chair of an acute trust or a PCT concerned with services in an area and you had problems in mental health, accident and emergency and maternity, there would not be much doubt about which two out of the three would win. One paper will not change that area. In other words, even if mental health is declared not to be Cinderella it is a long way from being clear that it will feel like that on the ground.
If anybody wonders whether I am alone in that, I refer them to this week’s Health Service Journal, which I happened to be leafing through on the way in. Page 9 says:
“Adviser says he was sacked for therapy views”.
I do not know whether that is true but he was worried about whether there was enough for the new therapy services. That links with page 13, which says:
“‘New’ talk therapy cash to come from existing funds”.
Again, I know no more than I am reading but if I go on to page 14, I read about:
“‘Despair’ over mental health cuts”,
being proposed by PCTs in the West Midlands, so I am not unique in having this worry. There is some evidence that the worry is real. I simply hope that my noble friend will be able to say how this strategy will be translated into real action on the ground.
Lord Patel of Bradford
My Lords, I, too, add my thanks to the noble Baroness, Lady Murphy, for calling this timely and important debate. As some of your Lordships will be aware, I have a keen interest in the subject of mental health, having been chairman of the Mental Health Act Commission for a number of years prior to its transfer to the Care Quality Commission. Also, as a researcher and service manager, I have a long history of working to improve experiences and outcomes for mental health service users, carers and families, especially those from black and minority-ethnic communities. I therefore welcome the Government’s strategy, which places experience and outcomes at its heart.
However, despite the excellent approach this strategy represents, there remain some areas that I feel should receive greater attention, especially with respect to the mental health experiences and outcomes of black and minority-ethnic service users. For example, I was disappointed to see that the proposed outcomes and the action plan appear to contain little on tackling inequalities with respect to ethnicity, especially given the emphasis placed on reducing stigma and discrimination, which is often compounded by issues such as racism, the high levels of fear and the lack of understanding among so many black and minority-ethnic communities. I shall raise two issues in this respect: first, how the funding for mental health services will be protected as a whole; and, secondly, how the new mental health strategy will ensure that the full range of data and information on ethnicity and mental health is used to the best effect.
I start with protecting the financial investment that I believe is vital, in light of the sweeping reforms to the NHS and the cutbacks across the public sector services. The Government have acknowledged that making cuts to mental health is a false economy, storing up problems in the long run with costly consequences. These consequences can be even more devastating for those communities that already face the burden of inequality and discrimination. While I am pleased to see the commitment to £400 million of investment for early intervention services, I, like the noble Baroness, Lady Murphy, and the noble Lord, Lord Newton, would like to see more on ensuring that that money is actually spent on the intended services and does not become a casualty of the severe and increasing pressures that we know local health and social care authorities currently face.
This is, however, not just an issue of money, as the proposed changes in the Health and Social Care Bill over commissioning are a source of particular concern, especially among many of those who work in mental health. There is enough evidence, as the noble Baroness, Lady Murphy, already said, from the experience of PCT-based commissioning to give serious pause for thought over whether GPs—whether in consortia or through commissioning agencies—will have the appropriate knowledge, experience and planning skills to ensure adequate mental health provision, particularly in specialist in-patient services. The increased focus on contestability could also mean the end of some of the more specialist services that we now have.
What assurances can the Minister give that mental health funding will be protected at local levels and what specific actions will be taken in the strategy to ensure that commissioning is appropriate and expert in relation to mental health? For example, can the Minister assure me that GP consortia will be subject under the Equality Act 2010 to the public sector equality duty?
Secondly, although the strategy highlights the importance of collecting and monitoring information on ethnicity and culture at local levels and how it can be better used to inform commissioning and service delivery, there is no reference to the importance of existing data sources, such as the Count Me In census. I must declare an interest as the original architect of the Delivering Race Equality in Mental Health programme, including designing the Count Me In census. Therefore, having been involved in the set-up of the Count Me In census, I am very concerned by this omission and by the continuing delays in publishing these vital data. They are almost 10 months overdue. This is at a time when we know from the most recent findings of the mental health minimum data set that:
“The proportion of inpatients who were detained during the year rose across all ethnic groups, but this was particularly noticeable for the Black group, of whom 66.3 per cent were detained in 2009/10 (compared with 53.8 per cent in 2008/09)”.
We also know that black and minority-ethnic patients are even more disproportionately represented, albeit by a small margin, in community treatment orders, something I warned could occur when these new orders were introduced if they were not accompanied by action to address the existing levels of discrimination and imbalances in representation in the mental health system. Against these disproportionate rises in numbers of black people subject to the powers of the Mental Health Act, the evidence and information provided by the Count Me In census is more important than ever. What specific actions will be taken under the strategy to ensure that the full amount of information on ethnicity and other equality strands is published and used to inform local planning and service delivery?
In summary, while there is much in this strategy to be recommended, and the overall approach is one I strongly endorse, the devil, as they say, is always in the detail, and it is the detail that we currently lack. I hope that the Minister will be able to provide some of that detail in answering my questions, and I also hope that we will see this strategy develop in a way that truly improves mental health services and well-being for all communities.
Lord Alderdice
My Lords, like other noble Lords, I am grateful to my colleague, the noble Baroness, Lady Murphy, for obtaining this debate, albeit, as the noble Lord, Lord Newton of Braintree, said, a brief debate in which it is not possible to deal with such a complex subject as mental well-being and a complex system for dealing with it.
I come to this debate with feelings very different from those of previous speakers. For the whole of my professional life, I spent half my time on Northern Ireland politics and the other half on developing mental health services, particularly psychological services, in Northern Ireland. As a young psychiatrist, I discovered that there were very limited services for alcoholism and drug dependence. There was no proper training for psychological treatments within psychiatry, so I devoted myself to working at that for the next 25 or more years. When I retired at the end of March last year, part of the reason for doing so was because I felt increasingly depressed about the way that mental health services were going. For the first 10 or 15 years, every year I could look at services, not just the one I was working in, but more generally, and see improvement and development, but for the past 10 or 15 years, everything seemed to get worse every year in a number of different ways. In devoting myself more to working in Parliament to try to make changes, this document is the first time in the past 10 or 15 years that I have felt seriously encouraged that people are beginning to address mental health and well-being problems in a proper and serious way.
I shall describe the document from two or three perspectives. First, it is the first document I have seen issuing from government that recognises that mental health and well-being go across all government departments. We talk about stigma. One of the key elements of stigma in mental health is that everybody in the community and right across government is very happy to deposit mental health in psychiatric departments and not recognise that education, maternity services and well-being in employment practices all contribute to mental health. We had a Government who demanded that people reconstruct the management of their businesses in such a way that bullying became good management to get the best out of things. It was neither good management nor good for people’s well-being. The point about this document is that it makes it clear that in business and management—which includes management within government—we have at our disposal the mental well-being of those who work in the services. We need to take that into account.
We can get into the details. I see that one Royal College of Psychiatrists document—No Health without Public Mental Health—is well represented but Self-Harm, Suicide and Risk, which I was involved in, is relatively little represented. In particular, there is not much recognition that self-harm is a different phenomenon from suicide; it is not just uncompleted suicide. In the details there are things that one could point out. At a high level this document seems to be an attempt to get recognition right across government and the healthcare services that not only in what people sometimes dismiss as the walking wounded but in serious, enduring mental illness—the schizophrenic disorders, manic depressive psychosis and the more organic disorders—there is a psychological component.
One of the difficulties in my own college is that for some years—it is not true more recently—there was such a focus on the biological side of things that the psycho-social became much less important. Many professionals, including some from my own profession, fell into the trap of thinking that the way to deal with things was to retreat into a biological approach. This document says, “No, I’m sorry, that’s not sufficient. We have to see the person as a whole”. Four hundred million pounds may not be a lot of money in terms of developing psychological services but at the moment it would not be easy to find all the trained therapists within the National Health Service who could go on to do the work. You cannot produce therapists at the drop of a hat, particularly in the psychological services. It will take some years to train them. One of my anxieties is that to spend the money quickly there will be a temptation to employ all sorts of people who might not necessarily be good therapists. The previous Government never got around to the statutory registration of psychological therapists, despite considerable pressure over the past 10 years from some of us.
As I look at this document, it is wholly possible to point out all the flaws and difficulties. We are starting from very difficult circumstances. However, it seems possible to understand from this that the Government are trying to point to a whole new direction in this document. I am not much enamoured of the term “big society”, which is used in this document and pretty much everywhere else. However, I do like the notion of active citizenship. When people come along with difficulties in their lives, it is not about what we do to them in healthcare services, but about how we engage with them and help them to engage with their lives.
I pick up on one comment in closing. The noble Baroness, Lady Murphy, whom I regard as my noble friend, talked about the danger that serious, enduring mental illness might not be dealt with because lots of other things might be espoused first, particularly in psychological therapies. It was not this Government who produced the notion of recovery models. However, the Government pointed out, albeit in a footnote, that recovery does not necessarily mean that you recover. It means, as it says in the footnote on page 16,
“living a satisfying, hopeful and contributing life even with the limitations caused by the illness”.
The noble Baroness is totally right. It would be Utopian to have the notion that mental illness can be done away with completely. It is part of the human condition for more of us, including some in this House, than we would like to believe. In the face of the enormity of that problem, we should not be dismayed by this report but encouraged by it.
The Earl of Listowel
My Lords, it is a privilege to follow the noble Lord, Lord Alderdice, given his career as a practitioner in mental health services. I second his desire to encourage the Minister and his colleagues the honourable Paul Burstow and the right honourable Andrew Lansley to take every opportunity to go out and visit services, schools, young offender institutions and the wider services catering for young people with mental health problems. There is tremendous anxiety out there about the impact of the cuts. It might be difficult to experience that but people need to see Ministers and Members of Parliament on the front line and know that there is interest in the issue and support for it.
I welcome this very timely and important debate initiated by my noble friend Lady Murphy. I am grateful that the noble Earl, Lord Howe, will reply to the debate, given his long experience in this area. We are grateful for that, given the challenges that lie ahead of us. I welcome the Government’s No Health without Mental Health strategy. I was particularly struck by the evidence that many smokers have a mental health disorder. I also welcome the fact that early intervention is emphasised. The work that the Government have commissioned from Frank Field MP, Graham Allen MP, Dame Clare Tickell and Professor Eileen Munro to look at how we can intervene early to improve outcomes for children is all very welcome and I am sure will be an important part of the strategy. Tim Loughton MP is a great example of someone who has got out there and found out what is happening on the front line. Practitioners have immense respect for him as he has done that. At a recent meeting on children’s centres, he spoke about the need to share best practice in Sure Start centres. I hope that there may soon be a means to do so. I understand that the Government are considering making a grant to organisations to hold a conference on that, which I welcome.
Unfortunately, I have a number of concerns. On a quick reading of the document, I saw no reference to the mental health of looked-after children and specialist looked-after children mental health teams. The statistics for the mental health of children, especially in children’s homes, point to a high degree of unfairness in this area. It needs constant thought and attention. CAMHS concerns me very much. A huge amount of CAMHS funding comes from local authorities. In the London Borough of Barnet, five-sixths of the funding for CAMHS comes from the local authority. That funding has been hit by the current cuts. Lots of thought needs to be given to how to support CAMHS at this time.
The report refers to targeted mental health services in schools—TAMHS. Very successful pilots have been run in schools but I understand that if there is no will or funding to sustain them, this early intervention, which is so effective, may be lost. The Minister is kindly giving careful thought to the future of the Cassel Hospital and the possibility of providing national funding. I know that he has been concerned about the vacancy rates in the family assessment unit. I understand that they have been rising for a number of years following a 2005 ruling in the High Court which forbade judges insisting that local authorities fund assessments at the Cassel Hospital. In short, the Cassel Hospital has not been funded adequately. It provides specialist services for families with very complex needs. I am grateful to the Minister for the attention that he is giving it. I should be interested to hear what other options he may be considering for these families. That interesting information would inform our further discussions on this matter.
There is concern that the Sure Start centres in the most impoverished areas are the ones most at risk of closing. I hope that the Government will listen to their adviser, Frank Field MP, and will consider ring-fenced funding if it seems to be necessary, or other means to incentivise local authorities to fund these fundamental early intervention services.
I have here a note about the number of commissioners who have already been lost, with all their experience in local authorities and the health service. There is a shortage of psychiatrists, as I have said. Clinical psychologists are more in abundance, but future generations may be put off by the fact that it is difficult for the current generation to find work. This profession is crucial. For example, Hackney’s social services have in the past three years experienced a reduction from 500 to 270 in the number of children taken into care, and it is astounding that a quarter of young people leaving care in Hackney have gone on to university—the highest proportion across the country. Hackney’s teams have included clinical psychologists with additional training to become systemic psychotherapists. Support from that sort of professional can make a huge difference, and I know that the noble Earl is considering a review of NHS professions. I hope that that consideration will be given priority.
To conclude, I welcome this strategy and hope that the Minister will take every opportunity to visit the services I have described.
Lord Touhig
My Lords, I join others in congratulating the noble Baroness, Lady Murphy, on securing this debate. She seems to have a knack of securing debates of this nature at an important time. In 2009, she secured a debate on dementia, and anyone who reads it will realise the power, information and knowledge that a debate of that sort in your Lordships House brings to the issue.
It seems that society increasingly expects GPs to have the answer to every health problem. While the demands on the National Health Service grow, more and more patients turn up at GP surgeries expecting answers to ever more complex medical problems, compared with, say, just 10 years ago. The plain fact is that GPs are inadequately equipped to provide the overspecialist diagnosis that many patients, perhaps unreasonably, expect from them. For me, the big worry is that the Government intend to place an even greater burden on GPs by making them the local health commissioners through GP commissioning.
Under the Government’s Health and Social Care Bill, local commissioners and GP consortia will be responsible for ensuring that the mental health needs of their local communities are properly and adequately met. The worry is that they are inadequately trained and prepared for this. GPs have a small degree of training in mental health and their knowledge of it is varied, sometimes with worrying consequences. In my former constituency of Islwyn, we have a wonderful group called SHADE. It is a self-help group of ladies who have suffered with a range of mental health problems, especially depression. When I first got to know the group many years ago, one lady who was suffering with depression told me that when she went to see her doctor he listened carefully to her problems and then said, “Nothing wrong with you, love. Go home and get your husband to buy you a new dress”. What worries me about the Government’s plans is the lack of any proposal to remedy such ignorance.
The one exception—and as a former Minister for Veterans I welcome this—is on page 45 of No Health without Mental Health, where there are proposals to provide training for GPs and other NHS staff who may come into contact with veterans with mental health needs. That is most welcome. If the Government propose to do this for veterans, it is an admission that there is a training gap, and the Government should extend this sort of training on general mental health matters to GPs. This would significantly decrease the risk of poor-quality mental health provision posed by some of the plans to give GPs commissioning powers over health provision.
As I understand the Government’s NHS changes, only a small number of specialist high-cost low-volume services, such as secure mental health services, will be commissioned directly by the new GP commissioning board. The majority of mental health services will be commissioned by GP consortia in place of primary care trusts. It will therefore be vital that GPs properly understand mental health and the services needed to help people with mental health problems. Yet, the Government’s own evidence on page 58 of No Health without Mental Health shows that only one in every six older people with depression discusses their symptoms with their GP, and fewer than half of those receive adequate treatment.
In my time as a Member of Parliament, too many elderly people came to see me and complained that they were unhappy with the care offered by their GP, who would often say: “What do you expect at your age?”. Senior citizens expect a first-class health service. Citizens of whatever age are entitled to and deserve that. The evidence suggests that if GPs are going to take responsibility for commissioning mental health services, it will be necessary for them to receive further training on how best to treat mental health problems. At the very least it will be necessary for the Government to carry out a full assessment of whether GPs are in a position properly to commission mental health services.
On page 51 of No Health without Mental Health, the Government say that they want GP consortia to be,
“well placed to understand the broad range of mental health problems experienced by people in the local population and to commission high-quality services across primary and secondary services”.
We can all sign up to that aspiration, but GPs will need further training. I fear that the proposal from the Government may simply be storing up even greater expectations of what GPs can do for their patients that will not be fulfilled, leaving many with undiagnosed and inadequately cared for mental health problems. Like other noble Lords, I welcome this document, but I see it as a work in progress rather than as the final answer to our difficulties.
Baroness Barker
My Lords, I, too, thank the noble Baroness, Lady Murphy, for securing the debate and for the first two minutes of her introduction. I will start by pointing out that both David Cameron and Nick Clegg, very soon after they took over as leaders of their respective parties, chose to highlight mental health as an area about which they felt very strongly and which they believed should be properly addressed in a way that the previous Government were not doing. In one of his first Prime Minister's Question Time, Nick Clegg challenged Gordon Brown on the lack of available access to talking therapies. That was a brave thing to do, because, as noble Lords have said, mental health remains a Cinderella part of the health service and not particularly popular. The Government are to be commended for sticking to promises made before the election and coming forward with a strategy that, as the noble Baroness charitably said, is aspirational. However, it is also comprehensive.
I say to noble Lords, in particular to those who were here a few years ago and who went through the misery of debating what became the Mental Health Act, that there is a stark contrast between the legislation that was passed by the previous Government and this document. I would much rather see a Government committed to, and putting resources behind, some of the aspirations that are in this document. Will it address serious and enduring mental health questions? Probably not. However, it addresses a lot of the issues that were highlighted during the passage of the Mental Health Bill as areas on which the Government needed to work. Therefore, there is much to be commended in it.
In particular, there is much to commend in the way in which the strategy picks up on many discussions that we had in your Lordships' House about how existing mental health legislation was applied disproportionately to different groups in the community, and how certain groups were suffering adversely as a result. It is refreshing to see a document that talks about the mental health of veterans and older people, lesbians and gay men, and people from black and minority communities. That is a refreshing change from the Government, and I strongly welcome it.
I was struck when I read the briefings that we were sent when people outside learnt that we were to have this debate. I looked for the criticisms. Most of them came from organisations such as the NHS Confederation and were not about the contents of this document but about the general position on health funding, to which noble Lords have referred. There was not a great deal to which people took exception in this.
The noble Lord, Lord Touhig, was right to focus on the key question of the ability and capacity of GPs to commission mental health services. At the moment, there is a great hue and cry about GPs’ capacity to commission a whole range of services, and some of the arguments are more compelling than others. It seems that on mental health there is a clear case for the Royal College of Psychiatrists and the Royal College of General Practitioners to work together to inform GPs in very practical ways about how they should go about fulfilling that commissioning process. Can the Minister say whether that is intended to be one of the priority areas in the work of the ministerial advisory group?
There is one very important thing that I wish to dig out from the depths of the strategy document. On page 54, in point 5.84 in the section on improving quality of outcomes, it is stated that payment by results currencies will not be setting-dependent. In lay terms and cutting through the jargon, that means that for the first time we will have a system in which the payment for treatment does not encourage practitioners to keep people in hospital. That is a significant breakthrough. During our discussions on the Mental Health Bill, I remember the noble Baroness, Lady Murphy, talking about the need to make mental health professionals understand that the transition between acute care and community care had to work better for patients. That one measure in itself could have a more profound effect on the organisation of services and outcomes for patients than almost any other, and I was very glad to see it.
Finally, I notice in the document that there is a passing reference to the Mental Health Act and to the increase in the number of community treatment orders issued under it. I well remember people who supported that Bill standing up in this House and saying that we had to support the legislation but that we could review how it was going. I ask the Minister how quickly that will be reviewed and how soon Members of this House and another place will receive evidence on the impact of the legislation. That underpins to a large extent the capacity of professionals to implement what I think is an extremely good strategy overall and one that we should welcome.
Baroness Greengross
My Lords, I join in congratulating my noble friend Lady Murphy on securing this important debate. The strategy is most welcome. It has a lot to commend it, especially the pledge to combat the stigma and discrimination that is still faced by so many people affected by mental illness.
In its opening lines, the strategy, one of whose key areas for action is to identify mental health problems and intervene early across all age groups, tells us that good mental health and resilience—I emphasise that word—are fundamental to our physical health, our relationships, our education, our training and work, and to achieving our potential. The use of “resilience” here and the rhetoric that follows it so early on in the strategy are interesting. They inform us that the main focus of the strategy is the very worthwhile desire to get people of all ages with mental health issues into work and to keep them there—an endeavour that deserves our full support. This might prove particularly hard in the difficult economic circumstances that we face. As chair of the All-Party Parliamentary Group on Corporate Responsibility, I heartily endorse anything that facilitates a better understanding of the contribution that people with mental health issues want to, and can, make to our economic recovery, and the critical role that employers can play in bringing that to pass.
One of the key examples that our group recently highlighted has been the Business in the Community campaign, Business Action for Working Well. Mental and emotional well-being is an important focus of that campaign. I can do no better than to quote Alex Gourlay, the chief executive of the health and beauty division of Alliance Boots and chairman of the BITC campaign, when he said,
“Employers need to take urgent action to promote the mental and physical health of their employees if they are to ensure the competitiveness of their companies in difficult, as well as prosperous, economic times”.
A small charity in south London is one such example. It trains people, some with severe physical as well as mental health conditions, to achieve NVQ qualifications or credits towards NVQ qualifications in IT, office skills and sometimes in horticulture, working in the nearby hospital grounds.
The key to the project’s success and to the achievements of the students is the sort of flexible working that they can cope with, so that fluctuating conditions can be accommodated by giving people certain agreed tasks to complete in a specific time, say one month, and not by measuring their achievements by the usual outcome measurements that we use. That enables their resilience to their conditions to be maximised. The sense of achievement of many of the people who gain an NVQ or part of one is quite remarkable. It can transform their sense of self-worth and, through that, their future.
In welcoming the strategy, I have some concerns that the section entitled,
“Improving outcomes for older people with mental health problems”,
majors on depression in older people, which is very welcome, but sadly gives dementia scant treatment. The document states that improving the quality of care for people with dementia and their carers is a major priority for the Government and that the Government are committed to more rapid improvement in dementia care through the local delivery of quality outcomes and local accountability for achieving them. As chair of the All-Party Parliamentary Group on Dementia, I would say that this is very welcome, but the strategy goes on to report that for every 10,000 people over the age of 65, 500 have dementia, as if in some way this were a low figure and not too troubling. We know that the reality is very different.
Research shows that more people fear being diagnosed with dementia above anything else, including cancer or even death itself. One million people in this country will suffer some form of dementia within two decades, and one in three people of 65 and over will die with it, yet 12 times as much is spent each year on cancer research, and six times as many scientists are working on how to treat tumours. Currently, as many as two-thirds of people who develop dementia are never diagnosed, while the best treatments can only help to reduce symptoms and cannot prevent the degenerative disease progressing. In Annexe A of the strategy an action within objective 4 is to,
“Implement the recommendations of Quality Outcomes for People with Dementia: Building on the work of the National Dementia Strategy”.
We know that in development of a dementia quality standard, the condition seems something of an afterthought in the strategy.
I also have a concern that the strategy might inadvertently imply that some people with mental health issues were unsuited to the world of full-time employment and are therefore, in a sense, second-class citizens.
The wording of the strategy tends to focus on contribution. I feel that that is too associated with condemning older people—those over working age, including those with early-stage dementia—to being in an unstoppable decline into residential care and to never being expected to be resilient or even interested in contributing to society, whereas we know that many people with early-stage dementia could remain engaged, independent and supported at home, making a significant contribution to their communities, perhaps supporting others who are in full-time employment.
My last point is that dementia is still not always treated as a health issue, but rather as a social ill that is funded, especially in the community, mainly through social care rather than as a health condition. Despite the fact that dementia confers a life expectancy of only five to six years, it remains the poor relation to cancer and heart disease in research funding, because it is not seen primarily as a health issue. We must change that, and I hope that the strategy will, because only by changing it can the ambitious challenge of the strategy to mainstream mental health in England be fully and effectively taken up by both commissioners and providers in health and social care.
Lord Layard
My Lords, I, too, welcome the debate. It is extremely timely, because it is a time of great opportunity for mental health services but also a time of great danger, as many noble Lords have said. I should like to begin with the opportunity. We have here an excellent strategy which provides a better deal for mentally ill people, especially the one in six adults with depression or anxiety disorders and the one in 10 children with mental health problems. If we take those two groups, we are starting from a very poor base where only a quarter of those people are at present in any form of treatment. It is great that the Government are giving that group a major boost through a specific strategy, the Improving Access to Psychological Therapies programme. I must declare an interest as a national adviser to the programme.
In the spending review, the Government have backed the strategy, with £400 million allocated. This must be the first time that specific money for mental health has appeared in the top six priorities for health spending in a spending review. That is wonderful progress. It is also very satisfying that the spending has been extended to include CAMHS, the Child and Adolescent Mental Health Services. Of course, the task is to ensure that the money gets spent to good effect. A key issue here is the role of local commissioners. The NHS operating framework gives clear instructions because, for the first time, improved access to psychological therapy has been made a national rather than a local priority for local commissioners. Again, that is major progress. The framework also requires session-by-session monitoring of outcomes and reporting, so that commissioners can see what they are getting for their money in both access, where there is a clear standard of 15 per cent of the mentally ill population, and in the quality of service, represented by the recovery rate, which is intended to be at least 50 per cent of those treated.
However, it is important that those key performance indicators are made publicly available, because that is the only way in which local commissioners, as well as providers, will be held to account by the public. It is important that commissioners understand that they really have to do something to deliver the key performance indicators. Perhaps the most important thing that they have to do, which was assumed in the calculations for the spending review, is to make sure that providers are employing sufficient qualified therapists—at least 40 for every 250,000 population. We should consider those as some of the most important jobs in the country. It is very exciting that the Government have a training programme in parallel with local service delivery to provide that number of therapists and it is important that the local commissioners then ensure that they are employed. We are starting from a situation where the NICE guidelines for depression and anxiety simply cannot be implemented in at least 40 per cent of the country. But, if the spending settlement is properly implemented, the whole country will be covered by 2013.
This is a major challenge and a real revolution if it can be brought about. It is in everyone’s interest that it is, including the whole of the NHS, because the waste in the current situation is terrible. It is not just a waste of lives and taxpayers’ money: one can show that improved access to psychological therapy will pay for itself twice over as regards the taxpayer. First, it will save more in incapacity benefit and lost taxes than it will cost. Secondly, the programme will save the NHS as much money as it costs.
We have evidence, unfortunately, only from the US, but we also have good evidence from 28 randomised control trials of cognitive behavioural therapy. Data were collected on the cost of the therapy and the subsequent healthcare costs of those treated and of the control group. In 26 of the 28 trials, the savings in subsequent healthcare costs were greater than the cost of the initial therapy, which is a cast-iron case. However, the danger is that we are in a world of cuts. In all previous worlds of cuts, mental health expenditure has been cut more than physical health. The studies that I have quoted show how incredibly short-sighted that would be even in terms of the costs of physical health. It must not be allowed to happen again.
Finally, I want to ask the Minister two simple questions. First, is it government policy that mental health expenditure should be cut by no more than expenditure on physical health? Secondly, if that is their policy, what steps will the Government take to make sure that this is what happens? I think that these are the key questions which lie behind much of what noble Lords have said today. I hope that the noble Earl will be able to help us when he replies.
Baroness Hollins
My Lords, I am grateful to my noble friend Lady Murphy for securing this debate, particularly as it is the first debate on mental health since my introduction in November. I, too, declare an interest. Although I began my medical career as a general practitioner, I have worked for probably 35 years as a psychiatrist, particularly working with people with learning disabilities and complex mental health problems.
As a former president of the Royal College of Psychiatrists, I am quite accustomed to arguing the corner for mental health. I remember writing to Gordon Brown when he was Prime Minister suggesting that when he spoke about health, it would be a good idea to use the phrase “physical and mental health”. When the word “health” is used, people, including doctors, tend to think about surgery and surgical interventions, but not about mental health. Gordon Brown and the rest of the ministerial team then referred to physical and mental health for about six weeks. I wondered why it did not last any longer and came to the conclusion that it was because of the difficulty in trying to understand the complexity of mental health problems, plus the discrimination associated with mental illness and the fear and ignorance which go along with that.
There was a time when cancer was spoken about in hushed tones. No one had the language or the confidence to speak openly about it. In many ways, mental illness today is where cancer was all those years ago. My vision is of a time when mental illness will be spoken about more openly by politicians, the public and medical professionals; when everyone has a language and the confidence to express what needs to be said and what needs to be done; and when people with mental illness and learning disabilities will be more fully accepted and included in society. I am delighted that these are the objectives of this excellent new mental health strategy, No Health without Mental Health. I applaud its public health focus and the determination expressed within it for parity of esteem.
At the end of my presidency in 2008, the Royal College of Psychiatrists launched its manifesto, A Fair Deal for Mental Health. At the time, the campaign pointed out that only 12 per cent of NHS spending was on mental health, a share that did not accurately reflect the human and economic cost of mental illness. I therefore welcome the recognition in this strategy that mental health problems cost England £105 billion every year and that these costs are incurred across several government departments, including health, education and criminal justice. The challenge will be to address the imbalance between investment in physical health services and investment in mental health services at this time of financial constraint.
The failure of commissioners and managers to make provision for the overlap between mental and physical conditions leads to expensive and unnecessary investigations, such as for medically unexplained symptoms, and for missed opportunities to treat, for example, depression associated with heart disease. People who are depressed are much more likely to die from heart disease even when their depression has been effectively treated. This points to an interrelationship between physical and mental health which is rather overlooked. I always say to medical students, “Have you noticed that the brain and the heart are in the same body?”. There is plenty to research in this interrelationship, but the separation between physical and mental health has not allowed us to look at it properly.
I did not see much mention of research funding in the strategy document, although I may have missed it, but research will be a critical friend in the move towards better mental health services. Here is the rub: for every £1,000 of charity funding for cancer research, just £26 is available for mental health research. The stigma associated with mental illness has a negative impact on charitable giving for mental health research. Mental Health Research UK, the first mental health research charity, is struggling to establish itself and would benefit from proper funding so that it can begin to be a significant player in the research arena. Government sources such as the National Institute for Health Research need to start giving priority to mental health research in order to redress the inequity.
Finally, I should like to comment on the provision of appropriate treatments for all patients with mental health problems. I welcome the proposed increased investment in the Increasing Access to Psychological Therapies project, in particular the expansion to engage with harder-to-reach groups, but I am concerned that there are still no plans to extend talking therapies to people with learning disabilities who, again as far as I can see, receive no mention in the strategy documentation.
The nuts and bolts of how to provide effective treatments for people with complex mental health needs, such as those with learning disabilities, are often poorly understood. Face-to-face appointments are clearly an essential component of treatment, but the specialised supervision, consultation and multidisciplinary liaison that is needed behind the scenes is expensive, although crucial to enable success. Highly specialist teamwork is the only way of both managing risk and enabling patients with complex needs to access appropriate treatments and reach better mental health outcomes. The pathway from primary care treatments for people with common mental disorders to specialist mental health services for those with complex problems needs to be commissioned carefully.
I know that the noble Earl and the rest of the health team are determined to improve the quality of mental health outcomes, but I seek assurances that established complex needs services for people with severe mental illnesses, including services for those with learning disabilities with a dual diagnosis of mental illness, will not be cut to pay for the new public mental health programmes.
Baroness Thornton
My Lords, the noble Baroness, Lady Murphy, has provided us with an opportunity to discuss this important issue, for which we should all be grateful. The Government published their new mental health strategy, No Health without Mental Health: A cross-government mental health outcomes strategy for people of all ages, on 2 February. It is designed to set the framework for the policy and development of mental health services for at least the next five years. It is accompanied by a call for action to set out the principles of change and urge co-ordinated action in delivering the strategy. I join other noble Lords in saying that this is an aspirational document and there is no doubt that it makes a powerful case. However, as is this Government’s habit, it does not contain goals and target-setting as a means to reach its objectives.
I welcome the strategy’s acknowledgement that mental health problems cost England £105 billion every year and that this burden spreads beyond health services to education, employers, the social security benefits system, housing, the criminal justice system, and families and communities. I also welcome its demonstrating how effective interventions and initiatives can reduce that burden and prevent needless suffering to individuals and their families.
I think that we are all familiar with policy documents that are excellent and long on analysis of the problem in question but unfortunately bring to bear solutions that lack the same passion, drive and specificity. I think that I am not alone in expressing this concern—the noble Lord, Lord Newton, and my noble friend Lord Patel are but two of the others who have done so. In the same week that the Government launched their mental health strategy, the Commons debated the revolution in the NHS that is the Health and Social Care Bill and the uncertainties that it may bring. At the same time, hundreds and thousands of people with a mental health problem will face a test of their incapacity evidence which is already suggesting great unfairness and causing great distress. If one adds to this the local cuts which threaten services that are vital to many, one concludes that the Government must expect a level of anxiety about the deliverability of the strategy.
I commend the work of the voluntary sector in this area. I did a trawl through the websites of Mind, SANE and Rethink to see what they had to say about the Government’s plans. I also had a look at their blogs to gauge their members’ reactions. Like most noble Lords and me, they give a general welcome to the strategy. However, I shall quote what someone on the Mind website said:
“The county council will cease to provide funding for our local branches of Mind, or indeed for any services for people will mental health problems. We, (mental health service users who attend any of the pitifully few groups or agencies available) were told that this is so we can all have more ‘choice’ by opting to fund organisations ourselves with personal budgets. In reality, people with life-long mental health problems are being weeded out at every stage of trying to access these budgets and will therefore be unable to attend anything. Centres such as those provided by local Mind charities may well have to close if there are no longer people who can afford to attend them. So much for ‘choice’. The future health and stability of those now left unsupported does not appear to concern the council. At a time when council budgets are being slashed, social care is under a great threat. Any talk of a ‘strategy for mental health’ is somewhat meaningless in the circumstances, particularly for anyone with long term problems”.
That is a point of view that the Government need to take very seriously.
Will the Government’s strategy work? For people who experience mental health problems, I suggest that it has to work. It is legitimate to ask questions about how it might be delivered. I agree with the noble Baroness, Lady Hollins, on the lack of mention of funding for research in the document. I make two points. First, multidisciplinary commissioning is vital for pathways of care. Some of the matters will fall within the remit of the public health authorities, some with the NHS Commissioning Board and some with GP consortia. This may risk fragmentation of provision. If co-ordination and co-operation are so important, why are the Government abolishing the National Mental Health Development Unit as part of their rationalisation of the arm’s-length bodies?
The second point is the greater societal challenge. We have to recognise that cuts will bring restrictions to education opportunities, unemployment and debt. The impact on people’s lives and their mental health cannot be underestimated. Debt and the risk of homelessness and family breakdown will have a huge, spiralling effect on stress and anxiety levels. There will be an even greater need for these services to be got right.
In recent times under the Labour Government, we saw the start of a positive change in public attitudes. Evidence clearly showed that we need to support people in the workplace and the wider community. I will be very interested to learn from the Minister the answer to the questions that the noble Baroness, Lady Murphy, and others have posed in this debate.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, it is always instructive and never less than a pleasure to listen to the noble Baroness, Lady Murphy, on the subject of mental health. Mental illness and its consequences affect us all, directly or indirectly. We know that one in four of us will experience mental ill health over our lifetime, and that one in six of us has a common mental illness at any one time. Underlying this is the overall financial cost of mental health which, as noble Lords have pointed out, is staggering—an estimated £105 billion a year to the economy as a whole—and the costs of treatment alone are expected to double in the next 20 years.
This is why we launched our mental health strategy, No Health without Mental Health, on 2 February. To support it we are making around £400 million available for expanding talking therapies through the improving access to psychological therapies programme. This will build up the essential skills base of the NHS and mean that we can start offering talking therapies across a wider range of mental illness and to a broader range of people. I was grateful for the supportive remarks of my noble friend Lord Alderdice in this context.
The noble Earl, Lord Listowel, was right to stress that early intervention is essential. We know that half of those with lifetime mental health problems first experience symptoms before the age of 14. That would be part of my answer to the noble Baroness, Lady Murphy, who voiced disquiet that by focusing on the mental well-being of the nation we were doing so at the expense of those with very serious mental illness. We know that early intervention is important. Also, 25 per cent of older people have symptoms of depression. Those are good reasons why this strategy encompasses the whole population. The strategy acknowledges the dimensions of the problem by covering the full age range of society.
It also makes clear an expectation of parity of esteem between mental and physical health services. Improved mental health and well-being is associated with a range of benefits, from improved physical health and life expectancy to better educational achievement and reduced health risk behaviours. The prerequisite for achieving this is to build the awareness and understanding of mental illness and mental well-being across society. We also need to tackle stigma and discrimination, and we have put this at the heart of the strategy.
Yet to shift public attitudes substantially requires a major and sustained social movement. Already Comic Relief, the Big Lottery Fund and the major anti-stigma campaign, Time to Change, which is led by Mind and Rethink, aim to inspire people to work together to end the discrimination surrounding mental health. We know from discussions with voluntary and private sector organisations that there is an appetite for an even more ambitious programme. We will give this social movement our full support and active participation.
I should make it clear that mental health is a priority across government; this is very much a cross-government strategy. Of course it is easy to set out principles but the big question is how do we make it happen, especially at a time of financial challenge. A number of noble Lords have asked that pertinent question. The ingredients for success will be leadership and collaboration across the country, drawing on the skills and insights of clinicians and partner organisations and involving service users as much as possible to shape services in line with local needs.
The new NHS architecture will provide a clear opportunity to support mental health and drive improvements in care. The three outcomes frameworks—for the NHS, public health and social care—will entrench mental health needs in service priorities and provide clearer accountability for results. At the centre will be Public Health England, which will build up the evidence and expertise around mental health interventions.
Finally, at local level we have GP consortia, driving up standards by bringing resource management together with clinical management for the first time. There is undoubtedly a need to build up the skills and awareness among GPs and we are working with the Royal College of General Practitioners to do so. I do not in the least quarrel with the noble Baroness, Lady Murphy, on that point. However, there are already many GPs with a real interest and expertise in mental health issues. Good commissioning of services must involve collaboration, so that GPs and mental health professionals communicate with and—above all, perhaps—understand one another. Again, I hope that the strategy can be a catalyst for these conversations to take place.
The noble Lord, Lord Touhig, expressed his doubts about the ability of consortia to commission mental health services, as did my noble friend Lady Barker and the noble Baroness, Lady Thornton. The intention is that commissioning GP clusters will commission most mental health services in the same way as they commission other services. However, they will not be doing this on their own; they will do so in line with guidance from both NICE and the NHS commissioning board. I say in particular to my noble friend Lady Barker that we are indeed working with the Royal College of General Practitioners, the Royal College of Psychiatrists, the Association of Directors of Adult Social Services and the NHS Confederation to develop guidance and support for GP consortia in commissioning effective mental health services. In addition, there will be opportunities for third sector and for-profit organisations to provide specialist commissioning advice on mental health to GP consortia.
My noble friend Lord Newton asked what mechanisms will be in place to see all this through. First, the Cabinet sub-committee on public health will oversee the implementation of the strategy. Secondly, we will establish an advisory group for mental health, composed of key stakeholders such as service users and those who care for them. This advisory group will work in partnership in realising the improvement of mental health outcomes for people of all ages. Between 2011 and 2012, the advisory board will identify actions in the transitional year to deliver the mental health strategy. Thereafter, and once the NHS commissioning board and Public Health England have been created, the board will become a focus for all stakeholders to discuss the details of how implementation of the strategy will take place and review progress. The board will advise on improved indicators for tracking progress against the mental health objectives that could be used locally, by the NHS commissioning board and potentially in future iterations of outcomes frameworks. Plans for the all-important structures that need to be there for implementation of the strategy to be successful are already in place.
My noble friend Lord Newton, the noble Lord, Lord Patel of Bradford, and the noble Baroness, Lady Thornton, expressed fears that the £400 million is not strictly speaking ring-fenced and therefore might not be protected. The answer to that is that the NHS operating framework mandates an annual expansion of IAPT services in line with our commitment. PCTs are currently drawing up their plans for next year to implement the operating framework. The plans that we have seen so far are consistent with the Government’s commitments to expand talking therapies. We will hold strategic health authorities to account for managing their delivery. Additionally, we are in the process of making sure that, through a range of communications, PCTs, managers and commissioners are aware of the importance of IAPT and the mental health strategy generally.
Lest there be any doubt, I should say that the £400 million is additional money. It was announced with the publication of the cross-government mental health strategy and is part of the 2010 spending review settlement for the department. It is in addition to the £173 million announced in the spending review in 2007, which is in primary care trust baselines for April 2011.
A number of noble Lords, in particular the noble Lord, Lord Layard, referred to funding cuts that are in prospect. I just say to the noble Lord that, as I am sure he knows, the NHS budget as a whole is protected; it is not going to be cut. I have already referred to the NHS operating framework as a mechanism to ensure that these plans are delivered. Of course, mental health services cannot be exempt from the need to make efficiencies, but any efficiencies made must be based on robust evidence and, more importantly, mental health services must be given parity of esteem with physical health services. That is the answer to one question posed to me—when decisions are made on how to save money. The mental health strategy points to ways in which efficiencies can be made while also improving quality through the programme.
My noble friend Lord Alderdice referred to the lack of focus on suicide and self-harm. We will be publishing a separate suicide prevention strategy soon.
The noble Lord, Lord Patel of Bradford, spoke powerfully about black and minority ethnic issues. On the question of Count Me In, the Care Quality Commission expects to publish the census report in April this year. Incidentally, the census was never intended to continue indefinitely; the mental health minimum data set has the potential to be an even better way in which to monitor what is happening. I understand that the data are to be collected quarterly rather than annually. The noble Lord also asked me whether GP consortia would be subject to the Equality Act, and the answer is yes.
The noble Earl, Lord Listowel, focused in particular on services for young people. One of the first things that we need to do is to develop agreement on the nature of the requirements for psychological therapies in children’s services and the best way in which to meet them. Officials have already held preparatory meetings to do this, and we are in the process of setting up a team to take this forward. It is very important that we get consensus on the way ahead, because we cannot simply use adult psychological therapies programmes as a one-size-fits-all template. The Government have increased the funding available for CAMHS to give an even greater flexibility to those at a local level, investing funds to expand access to psychological therapies for children and young people. That will enable the development and initiation of a stand-alone programme to extend access to psychological therapies, building on learning from the IAPT programme.
The noble Baroness, Lady Greengross, referred to the other end of the age spectrum and older people, and suggested that the strategy does not say quite enough about that dimension of the issue. The mental health strategy talks about the problem of depression among older people and recognises that only one out of six older people with depression discusses their symptoms with their GP. It sets out the importance of early intervention, such as befriending programmes, which can be very helpful in tackling the social isolation associated with depression. In the public health operating framework, we are consulting on indicators that are very relevant to older people’s mental health. The mental health strategy also sets out the importance of ensuring that psychological therapies are accessible to older people as the programme rolls out nationally.
My noble friend Lady Barker referred to community treatment orders. Our view is that they are potentially useful, but we need to be certain, as she rightly said, that they are being used properly in patients’ interests and do not undermine confidence in the Mental Health Act. She was right that the coalition parties expressed doubts about CTOs when we were in opposition. We intend to keep the use of these orders under review, and I would be happy to write to her with further details on that.
The noble Baroness, Lady Hollins, referred to research. The Department of Health, through the National Institute for Health Research and the Policy Research Programme, has invested significantly in mental health research and will continue to support high-quality mental health research. The NIHR will also continue to work with research councils and other funders to co-ordinate research efforts consistent with the recently published MRC review of mental health research. We are increasing spending on health research in real terms over the next four years.
The noble Baroness, Lady Thornton, referred to the closure of the National Mental Health Development Unit. We are clear that at a time when the NHS budget is under pressure, we need to find efficiencies so that we can invest in front-line services. We are working with the Royal College of General Practitioners and the Royal College of Psychiatrists to produce robust guidance for GP commissioners, as I have already mentioned.
I firmly believe that this strategy represents an unprecedented opportunity to improve support, to prevent illness and to make mental health issues a more accepted part of everyday society and everyday life. We intend to put every possible effort into making that happen.