Mr Kevan Jones (North Durham) (Lab)
I congratulate the hon. Member for Loughborough (Nicky Morgan) and the Backbench Business Committee on securing this debate, and I pay tribute to her very well-informed contribution. She is obviously a great champion for people who in many cases do not have a voice in the health system. Let us hope that by securing this debate we can give those people the voice they need, and not only, as she says, in the health service; we also need to get the message across to employers and others that mental health issues are not an inhibitor to a good and successful career and a fulfilled life. I shall discuss that in a moment.
I declare an interest as the president of my local Chester-le-Street Mind group. I have had an interest in mental health for a number of years. The hon. Lady mentioned the role of the voluntary sector. It plays a fantastic role, not only in promoting the issue of mental health but in delivering services. In some cases, these organisations are better vehicles for delivering this localised help than some of the larger companies referred to by my hon. Friend the Member for Islington North (Jeremy Corbyn), or even the NHS itself.
The hon. Lady said that one in four people could suffer from mental health problems in their lifetime. The hon. Member for Southport (John Pugh), speaking from the Lib Dem Front Bench, is both right and wrong in what he said. Some people do have mental health issues because of events in their life—crises happen and people can get over them in a short time—whereas others have long-term conditions that have to be lived with throughout their life, by way of drug treatment and other effective therapies, as the hon. Lady said. There is a big difference between those two situations. Anyone in this Chamber or any of their family members could suffer from short periods of mental health illness or be long-term sufferers. That is the important thing to get out of today’s debate.
We also need to address the cost, which the hon. Lady mentioned. I am thinking not only about the cost to the NHS, and the personal cost to individuals and their families, but about the cost to UK plc. I reiterate that mental health issues can affect anyone. I know general practitioners who have gone through periods of severe depression. I know one who works as a consultant cardiologist and is brilliant in his field but who lives with mental health issues, and has for many years. He has a very understanding employer and is very open about it. Let us not say that there are any boundaries in mental health, because there are not; these issues can affect anyone in society.
I wish to discuss two issues, one of which is the effect of funding on mental health. The other relates to the welfare reform changes, to which my hon. Friend the Member for Bolton West (Julie Hilling) referred. They are having a disproportionate impact on people with mental health issues. I accept the view of the hon. Member for Loughborough that we do not want to get into a party political debate, but there is unjoined-up thinking in some parts of the coalition’s policy. I must say that I saw exactly the same thing when I was a Minister, when one Department does something that has an effect on others, and it is sometimes difficult to get round those circles. However, local authorities in the north-east are clearly having to cut back on funding for this. Mind has said in the briefing note it sent to us for today that about 22% of its funding at the local level has been cut. That is a shame because, as I said, those organisations are sometimes the best at not only being advocates for local mental health services, but at providing care. In regions such as my own in the north-east, funding is vital for those organisations. When I talk to local mental health professionals and charities, I find that it is unfortunately a fact of life that economic conditions at the moment mean that the demand for services is increasing.
The hon. Member for Loughborough referred to the Health and Social Care Act 2012, and I agree with her that it does present some opportunities, if things are done properly. Chester-le-Street Mind, under the great leadership of Helen McCaughey and her husband, Charles, delivers a local therapy service, commissioned by the primary care trust, and it is great. It is carried out in the community, and that is the model that I like to see. The only concern I have, from talking to GPs over the years, is that although some of them are passionate about mental health and understand it, others do not. The challenge for the new commissioners is to take a bold step and say that some of these services can be delivered in the community by groups such as Chester-le-Street Mind and others. The Government might have to be aware of that nationally. As my hon. Friend the Member for Islington North said, this does not have to involve just large companies, because the approach I have described would be effective. That is my only concern: that although I know some very good GPs, including my own, who have a clear understanding of mental health issues, others are not very good at giving this appropriate priority—I am sure that the hon. Lady is aware of some of those. We are thus presented with both an opportunity and a risk.
The Minister of State, Department of Health (Mr Simon Burns)
I am extremely grateful to the hon. Gentleman because he is making an extremely good point, but does he agree that, under the reforms and the new NHS, a crucial role will be played by the health and wellbeing boards, which are there to monitor and ensure that the local health needs of local communities are provided for?
Mr Jones
Yes, that is one of the key roles of those boards. Again, however, it will be important to ensure that we get the right people on those boards—for example, counsellors who really understand mental health. As the hon. Member for Loughborough said, people have empathy in respect of cancer, but do not quite understand mental health. I agree with the Minister that it is important that the boards are the counterweight to ensure that that happens, but I think that central Government also have to play a role in ensuring that it happens. As I say, we have some great opportunities here and the commissioned work that Chester-le-Street Mind delivers is excellent. In addition, it is cheap compared with some of the major contracts in terms of delivery, because it is delivered by well-trained professionals and by very committed and hard-working individuals in the community.
A lot of mental health charities also rely on charity funding from organisations. In the north-east this funding comes from, for example, institutions such as the Northern Rock Foundation, which has now been taken over by Virgin Money. There is real concern that as those sums contract, the money going into mental health services from those groups will also contract. We need to keep an eye on the situation to ensure that, be it through the lottery or through organisations such as the Northern Rock Foundation or the County Durham Community Foundation, where funds are limited because of the economic crisis, mental health gets its fair share of the funding available. I mean no disrespect when I say that people give happily to Guide Dogs for the Blind or to cancer charities, but it is very much more difficult to get a lot of people to recognise and give money to mental health charities, unless they have been through or had a family member who has been involved in mental health issues. We need to be wary of that, too.
I now wish to discuss the welfare benefit changes, which my hon. Friend the Member for Bolton West mentioned. I commend Mental Health North East, a very good group in the north-east that has interacted with the Department of Health. It is an umbrella group of mental health charities that not only campaigns for and raises awareness about mental health but delivers services to mental health charities and individuals. The organisation is run by a very dynamic chief executive, Lyn Boyd, and is made up of paid individuals and a large number of volunteers, many of whom have personal experience of mental health issues. They are very good advocates, not only ensuring that mental health is kept high on the political agenda but interacting very successfully with the Department of Health in consultations and so on.
One piece of work that that organisation has considered is on a matter that I have increasingly seen in my constituency surgeries. There are people with mental health issues who were on the old incapacity benefit and are now on the new employment and support allowance and who are, frankly, being treated appallingly. The way that is being done is costing the Government more money in the long term. I know that it is not the direct responsibility of the Department of Health, but some thought needs to go into how we deal with the work test for people with mental health illnesses. I am one of the first to recognise that, as most of the professionals say, working is good for people’s mental health; it is important to say that. However, we must recognise that certain people will have difficulties with that. If we are to get people with mental health problems into work, we must ensure that the pathway is a little more sympathetic than the one we have at the moment.
Another massive problem is the work needed with employers. If employers are going to take on people with mental health issues, they will have to be very understanding to cope with those individuals.
The Minister of State, Department of Health (Paul Burstow)
There is no health without mental health. In that simple statement I sum up the coalition Government’s approach to mental health.
In contributing to this important debate, I start by congratulating my hon. Friends the Members for Loughborough (Nicky Morgan) and for Broxbourne (Mr Walker), among others, on tirelessly pursuing the case for having this debate on the Floor of the House. It is one of the rare debates that we have on this subject, and it clearly airs the issues that are so important to so many of our fellow citizens.
The hon. Member for North Durham (Mr Jones) said that it was a privilege to have the job—the vocation—of being a Member of Parliament, and I could not agree with him more. Sometimes, that privilege involves the surprise that we can still experience in the Chamber when debates are genuinely authentic and when people speak from the heart. I thank him for his candour and honesty; we need more of that. The chair of the all-party parliamentary group on mental health, my hon. Friend the Member for Broxbourne, talked, with humour and much else besides, about his experience with obsessive compulsive disorder. Anyone living and struggling with such conditions, who has not perhaps reached the point of wanting to talk about it, will feel huge respect for both Members for bringing the attention of the House to these matters. They have made us all wake up to something that we ought to know, but that we too often forget. That is that mental health is not a “them and us” game; it is about us—all of us. It touches us all in one way or another.
I am probably not going to be able to do justice to every contribution in the debate, not least those that I have not yet heard, but I assure hon. Members that I will continue to listen throughout the remainder of the debate, and that if any issues arise that I have not covered in this speech, I will write to the Members concerned to address those points.
The hon. Member for Strangford (Jim Shannon) made some important points about the support for our veterans, and for our armed forces more generally. This Government have done a lot in that regard—not least the commissioning by the Prime Minister of my hon. Friend the Member for South West Wiltshire (Dr Murrison) to produce his report, “Fighting Fit: a mental health plan for servicemen and veterans”. The report deals with many of these issues, and the Government take them, and the action that they require, very seriously.
Mr Kevan Jones
I congratulate the hon. Member for South West Wiltshire (Dr Murrison) on the report, but would the Minister acknowledge that it built on a lot of the work done by the previous Government, which I was responsible for?
Paul Burstow
I hope that there will be cross-party consensus on these issues today, and I shall take the hon. Gentleman’s question in that spirit. He makes a fair point. This is about building on what is working, and ensuring that it can work even better. The work done by my hon. Friend the Member for South West Wiltshire has certainly accelerated the pace.
When the Deputy Prime Minister and I launched the mental health strategy last year, we recognised the need to tackle the root causes of mental illness as well as ensuring that community and acute services provide timely treatment and care. We placed a strong emphasis on recovery from a human, rather than just a medical, perspective. We also made it clear that delivering significant improvements in people’s health and well-being requires parity of esteem between physical and mental health.
I know that some hon. Members are concerned that not enough emphasis has been placed on acute and in-patient care. Let me be clear. Our plans to provide a safe, modern, effective mental health service give equal emphasis to the full range of services, from public mental health and prevention through to forensic mental health services. This is about people receiving high quality, appropriate care when they need it. If services can intervene early—the case for that has already been powerfully made—so that mental health problems can be managed in the community before more serious problems develop, that should result in acute in-patient care being made available more quickly for those who need it.
My hon. Friend the Member for Loughborough mentioned the concerns raised by the Association of Chief Police Officers about places of safety. In partnership with the Home Office and the police, we are examining how to ensure that health services are properly commissioned in custodial situations. I would be only too happy to meet her and the ACPO mental health lead to discuss those issues further.
Jeremy Corbyn
Will the Minister look carefully into the circumstances of people who die either in police custody or in a mental health institution as a result of a mental health issue, to determine whether adequate forms of inquest and inquiry exist, and whether adequate lessons are being learned from the experiences? In view of what is going on in one or two inquests at the moment, I feel that there are some quite serious deficiencies in that area.
Paul Burstow
I thank the hon. Gentleman for his question. May I undertake to write to him about that matter in more detail? It has come up in our work on our suicide prevention strategy in relation to the nature of suicide verdicts, and narrative verdicts in particular, in coroners’ courts. I would be happy to come back to him on that issue.
In the past year, we have made progress across a broad front. We have committed £400 million to make psychological therapies available for adults of all ages, as well as for people with long-term health conditions and with severe and enduring mental illness. When it comes to our focus on recovery, the latest figures show that 44.4% of those who complete programmes recover and that more achieve lasting improvement. That puts us on track to achieve our target rate of recovery of over 50%.
Given that we know that the first signs of more than half of all lifelong mental illnesses can be detected in adolescence, we have to go further. That is why the Government are breaking new ground by investing in a new training-led approach to re-equip children and young people’s mental health services to offer a range of psychological therapies. I pay tribute to the leadership shown by YoungMinds. Without its support, we would not have come as far in this area as fast as we have.
I want to say something about the necessity of achieving the best possible outcomes for people in mental health crisis. Secondary mental health services across the country have made significant changes, both in community and hospital settings, including the provision of alternatives to psychiatric hospital admission. For example, more than 10,000 people with an early diagnosis of psychosis were engaged with early intervention services last year. That is the highest figure ever recorded. The improvements in community-based early intervention services are driving up standards of care, as well as reducing the demand for hospital admissions. I freely acknowledge that there is more to do and I take on board the point that my hon. Friend the Member for Broxbourne made about the need to look at the variability in the accessibility of mental health advocacy.
The development of recovery-focused services is a critical part of the Government’s strategy. That work is being led by the NHS Confederation’s mental health network and the Centre for Mental Health. They are supporting pilot sites that cover almost half of England and are making the kind of changes that service users have sought for years. The programme has identified 10 key changes to the way in which staff work, the types of services that are provided and the culture of organisations to embed recovery principles into routine practice.
When I visited the South West London recovery college, I heard powerful personal testimonies from people who were living purposeful and fulfilling lives, and who were living with their illness rather than having to be cured of symptoms or illnesses. It is important that recovery is not just seen in medical terms, but is self-defined. Students at the college learn not only how to manage their condition, but skills to help them back to work and to form new relationships. Some become lecturers at the college themselves. I was told that being called a student, rather than a patient, helped people take control of their recovery, gave them more confidence and, crucially, made them feel normal, as opposed to being treated as a helpless, passive recipient of care.
Part of a good recovery is the ability to exercise more control over one’s life. In health care, that means that there must be more shared decision making and choice. In opening the debate, my hon. Friend the Member for Loughborough mentioned the principle of “no decision about me without me”. Undoubtedly, the any qualified provider policy and tariff reform have a part to play in that.
Adam Afriyie (Windsor) (Con)
Many of us recognise that many people who come to our constituency surgeries, perhaps with a housing benefit inquiry or other benefit inquiry, are actually struggling with mental health challenges. It seems to me that the lack of control that results from the way in which Government services are designed can be a great contributing factor to stress and, therefore, to depression. The Minister is speaking about control. Can the design of public services, such as housing benefit and other benefits, be taken into account as a way of relieving the stress on a great number of our constituents?
Paul Burstow
That intervention rather helpfully moves me on to the point that has been made by several hon. Members about Atos. Although it is not my ministerial responsibility, a number of important points have been made about how it operates in particular cases. I will ensure that those points are taken into account by my ministerial colleagues at the Department for Work and Pensions. I will gladly pass them on.
Stephen Timms (East Ham) (Lab)
The Minister will know that mental health charities have proposed changes to the mental health descriptors in the work capability assessment for employment and support allowance. There seems to be some delay in implementing those. Will he pick that up in his discussions with his colleagues?
Paul Burstow
I will certainly act as the messenger and pass that point on, as the right hon. Gentleman has requested.
Stigma has been referred to in this debate. It is undoubtedly one of the biggest barriers to access to mental health services in this country. The Government are determined to reduce the prejudice and discrimination that surround mental health, but we recognise that we cannot do that on our own. That is why Mind and Rethink Mental Illness have developed a major anti-stigma programme called “Time to Change”. That campaign is working and is delivering significant behavioural change across society. That is why the Government are contributing the substantial amount of £16 million up to April 2015.
Mr Matthew Offord (Hendon) (Con)
The Minister says that the Government wish to reduce the stigma surrounding mental illness, and I accept that. Does he agree that the decision of the Department of Health in 1994 to hold an independent inquiry into every death involving someone who has suffered mental illness or been part of the mental health system continues to perpetuate that stigma?
Paul Burstow
That is an important and challenging point, and I will want to go away and think about what we do. For patient safety, we still need to learn lessons when things go wrong in our system, acknowledge when things have not been done properly and put them right. In that sense, confidential inquiries are an important part of the learning mechanism. One point of frustration that I hear in debates in the House and see in correspondence from hon. Members is the sense that lessons are not learned. As part of our reforms, with the NHS Commissioning Board taking on responsibility for patient safety, we need to ensure that that is not the case in future.
We are investing £16 million in “Time to Change”, and we were delighted when Comic Relief decided to put in an additional £4 million, one of the biggest grants that it has ever made.
I wish to make another point that touches on the contributions of my hon. Friend the Member for Broxbourne and the hon. Member for North Durham. One in five people still think that anyone who has a history of mental health problems should not be allowed to hold public office. How many former Presidents, Prime Ministers or Ministers would have been excluded if that view had been applied? [Hon. Members: “Churchill.”] Precisely. Such a law is as outdated as asylums and as outdated as many of the attitudes that sit behind it. It has to be consigned to the history books just like asylums have been, and under the coalition Government’s watch, it will be. I congratulate the hon. Member for Croydon Central (Gavin Barwell) on securing a slot for a private Member’s Bill on the subject.
Looking ahead, although we have made progress there are still big challenges to tackle. Reference has been made to the implementation framework that will be published to support the roll-out of the “No health without mental health” strategy. That framework has been produced in conjunction with five national mental health organisations—Rethink Mental Illness, the NHS Confederation, the Centre for Mental Health, Turning Point and Mind—and many others have been involved.
We have previously had a very good debate about “Listening to Experience”, Mind’s excellent report on acute and crisis care, and Mind’s policy team have been directly involved in ensuring that the framework delivers on those issues. It will provide a route map for every organisation with contributions to make to improve the nation’s mental health. It will spell out how progress will be made, measured and reported.
What does success look like? To me, it means more people having access to evidence-based psychological therapists; services intervening earlier, particularly for children and young people; services focusing on recovery and people’s needs and aspirations above all; and service users and carers being at the heart of all aspects of planning and service delivery.
Today, economists tell us that mental ill health in this country costs £105 billion a year, and that is just in England. If we succeed and put in place the right combination of public health, anti-stigma policies, accessible psychological therapies and excellent community and acute services, we can dramatically reduce that figure. Put another way, if we can deliver the right evidence-based treatment to children and young people so that their conditions do not persist into adulthood, we can prevent as many as two in five of all adult mental health disorders. As a society, we have made huge progress in how we recognise people’s mental illness, but despite that we have not fully accepted that mental health is equal to physical health and that parity of esteem is needed between the problems of the body and the problems of the mind. That is the challenge—
Dr Lewis
I have waited many years to intervene on a Minister in his final sentence, and I have achieved that today.
Does the Minister accept, having made a convincing case for people being able to live with their illnesses by being at home, that part of the reassurance that they need to do that is to know that in periods of acute crisis, there will be a bed available for them should it be needed? That should be not only for detained patients but for voluntary patients.
Paul Burstow
One thing I did not say—I was trying to cut down my remarks—was that there is an essential need to give more people the ability to control their health care through crisis plans. Crisis plans are an opportunity for people to make a statement in advance on how they wish to be treated in the event of a mental health episode that requires an intervention from mental health services. We know that when the plans are in place, they make a huge difference to the need for admission, and that they can reduce the length of stay. We need to ensure that there is a sufficiency of beds so that people can get appropriate treatment, but we also need to ensure that there is much more focus on good, community-based intervention at an early stage. Getting that balance right is always difficult for health commissioners to achieve—I know my hon. Friend is struggling with that in his patch at the moment.
Those are the challenges the NHS faces. They are challenges not just for our health commissioners and providers but, as this debate has clearly demonstrated, for our whole society. We can transform mental health in this country only if we transform our attitudes. This debate plays an important part in that.
Andy Burnham
We must. Perhaps I am about to make more of a political point, but as has been mentioned so eloquently today by my hon. Friend the Member for North Durham, as well as the hon. Member for Strangford (Jim Shannon), although the trend is upwards—that is happening come what may: I mentioned the financial crisis, during which the rate has jumped up, including in our time in government—the cumulative effect of some of the benefits changes on some of the most vulnerable members of society, coupled with the withdrawal of social care support by councils, means that, right now, some people out there are suffering very badly indeed. That is part of the explanation for the worrying figures that my hon. Friend has just given the House. The Government need to have a look at what is happening out there and whether or not some people are struggling with mental health problems because of the extra stress that other factors, particularly financial, are putting upon them.
I welcome the Minister’s commitment to the improving access to psychological therapies programme, but I hear that waiting times for it are increasing in parts of the country where GPs face much longer referral times. Indeed, a Mind survey of 2011 said that 30% of GPs were unaware of services to which they could refer patients, beyond medication. That tells us that we still have quite a long way to go. IAPT needs protecting and nurturing; it needs to come with a national direction in the operating framework. In the new and changing NHS world, we cannot allow it to be simply whittled away. More broadly, we need to look carefully at commissioning and find out whether GPs have the right skills to commission properly for mental health. We need to consider what the precise commissioning arrangements for mental health are, as there is still some confusion out there about them.
Paul Burstow
One of the key aspects of the NHS Commissioning Board’s work in authorising clinical commissioning groups will be to assess their capacity to commission in mental health. As I am sure the right hon. Gentleman knows, the Royal College of General Practitioners is currently exploring what the extra year of education and training will involve, as we move forward to ensuring that mental health is part of it. I think it is a very important innovation.
Dr Sarah Wollaston (Totnes) (Con)
I congratulate my hon. Friend the Member for Loughborough (Nicky Morgan) on securing this important debate, and I pay tribute to my hon. Friend the Member for Broxbourne (Mr Walker), whose speech has immediately entered the list of my top 10 favourite speeches. I thank and commend him for the work he has done over many years as chair of the all-party parliamentary group on mental health.
I state from the outset that I am married to an NHS consultant psychiatrist and that my husband is involved in providing briefings to all Members on behalf of the Royal College of Psychiatrists. For that reason, I think it best for me to confine myself mostly to some personal reflections and some concerns that have been raised in my constituency, and in particular to address the issue of stigma.
As we have been told today, one in four people will experience mental illness at some point in their lives. We have heard powerful speeches about that from a number of Members. Like the hon. Member for North Durham (Mr Jones), I have experienced severe depression: at the happiest time of my life I experienced an episode of post-natal depression, so I know what it is like. I am sure that many other Members and people who are following today’s debate will know exactly what it is like genuinely to feel that your family would be better off without you, and to experience the paralysis that can accompany severe depression.
It has been rightly said today that there is concern about the way in which some GPs handle depression, but I want to make it clear that in my own case, accepting that I had a problem and seeing my GP was very much part of the road to recovery. I think that we should be careful when we talk about how GPs manage depression, because I can tell the House—not only on the basis of my personal experience, but on the basis of what I have heard from others—that there are many GPs out there who provide an excellent service, which I think can only be assisted by a move towards longer appointment times and better training.
We have heard today about the various terms that people use for mental illness. Earlier, we heard it described as a mental health “experience”. I would say to anyone who is listening to the debate that an experience of depression makes many people stronger and more understanding. I am absolutely sure that my own experiences of depression and recovery—recovery is very important—caused me to become a much more sympathetic doctor, and I hope that it made me a more sympathetic and understanding MP, able to recognise the issues in others and respond to them appropriately.
I want to sound a note of caution about employment and depression. Many Members have rightly mentioned the issues surrounding Atos assessments, and I was glad to hear the Minister say that he would address himself to some of the concerns that had been expressed, but I think that we should be careful about making assumptions. We should not assume that people with depression are unable to work; we should individualise the position.
When I returned to work after having a baby, I was still suffering from severe panic attacks—especially when travelling on the underground—and in retrospect, I realise that I was still significantly depressed, but going back to work was part of my recovery. I know that it can be difficult to challenge the ideas of people who are depressed, but I think it important to present them with challenges and encouragement at some level, because depression is sometimes followed by a crisis of confidence, and getting back to work is part of the road to recovery from depression, however difficult it may feel. We should not make generalisations and assume that no one can return to work when they are depressed.
I pay tribute to all those who help people with mental illness, including the many volunteers in all our constituencies, and I pay particular tribute to a voluntary group in my constituency called Cool Recovery. It is an independent mental health charity which cares for a number of people—not only those who have experience of depression, or are currently living with depression or other forms of mental illness, but those who have recovered from mental illness, and those who care for people who suffer from it.
I feel that such voluntary sector groups are essential if we are to realise some of the benefits that can come from the Health and Social Care Act 2012. I was concerned to hear from the volunteers at Cool Recovery that they do not feel they have been sufficiently involved in the commissioning process, and that there are real anxieties about the extent to which the user voice and the voluntary sector voice are being heard in the new arrangements. Perhaps the Minister will give us an update on what is being done to ensure that there is adequate representation for the user voice and the voluntary sector at every stage on HealthWatch, on health and wellbeing boards, and right up to national level at the NHS Commissioning Board.
Paul Burstow
I give an undertaking to answer those points in the letter that I will write to Members.
Dr Wollaston
I thank the Minister for that, and I look forward to reading his response.
I was pleased to hear that my hon. Friend the Member for Croydon Central (Gavin Barwell) will introduce a Bill to remove stigma. From talking to service users and those who have recovered from mental illness, it is clear to me that they are entirely capable of taking a full part in every aspect of life in their community and workplace, and in our national life. I was glad that the Minister and shadow Minister gave their full and unconditional backing to that Bill, as it will mark a very important step in removing the stigma of mental illness. I also join the Minister in paying tribute to the work of Time to Change, and I hope he will commit to continuing to give support to that organisation.
Some 22% of the disease burden in England comes from mental health issues, and it is time that we recognised that in our local and national commissioning. The mental health strategy is excellent, but we now need to ensure it is implemented. I know the Minister has set up a cross-ministerial group centrally, but who in this new system will be accountable for the successful implementation of the strategy locally and regionally—and what levers for change can they exert, and what sanctions will there be if it is not carried out?