NHS: Mental Health Services
(11 years, 7 months ago)
Lords ChamberRead Hansard Text Read Debate Ministerial Extracts
Lord Alderdice
To ask Her Majesty's Government how they propose to strengthen the provision of mental health services in the National Health Service.
Lord Alderdice
My Lords, the noble Lord, Lord Layard, and his colleagues at the Centre for Economic Performance produced an excellent document in 2006, The Depression Report. This important document pointed out that, within the community, a massive amount of distress was caused by depression and anxiety. They were a major form of deprivation of normal life—one which was going largely untreated for the majority of patients. They invoked huge economic cost to those concerned, to their families and to economic life in the country. He and his colleagues pointed out that there were treatments available at that time and they were not incredibly costly or unnecessarily long-term.
Therefore, the report recommended a substantial investment in the training of therapists in NICE-approved training, working in teams and supplied with centrally commissioned funding. Over a period of seven years, this would achieve a major change in providing psychological therapies for people suffering from depression and anxiety. This was a very important report, but it was also an effective one, because based on that—and with much other work—the noble Lord, his colleagues and others who supported him were able to persuade the Government to make a significant investment at the time and to press for substantial changes.
Even at the time, I was a little anxious that the focus of this whole programme to increase access to psychological therapies was on cognitive behavioural therapy and some other therapies approved by NICE. One of the reasons for that was not that I had any kind of crib about those approaches to therapy, but because it seemed to me that they were relatively new and espoused with a degree of evangelical zeal. One of the things that we do know, after a long period, is that every new therapy that comes in—when it is passionately pursued by committed people—very often shows itself to be effective with patients. Then, after a period of time, it is maybe not quite as effective: not because it is not a useful therapy or a good approach, but because it is probably the case that most of these approaches to therapy, given the right therapist—the person with the right personality and training—the appropriate patient and the development of a therapeutic relationship, can be substantially effective. With the wrong personality of therapist, the wrong personality of patient and the wrong problem, they can make the situation much worse. So we know, for example, that if we use short-term therapies for people with certain kinds of personality disorders, it can make the situation much worse rather than better. Those are patients who require a longer-term approach to therapy and often a multidisciplinary team bringing various different kinds of skills.
I am not terribly surprised now to find, for example, that although the Swedish Government spent almost £200 million on training therapists and providing services that were almost exclusively CBT—other kinds of therapy were pretty much set aside, which was not the case with IAPT, to be fair—they began to conclude, as was published recently in the major Swedish social work journal, that this was not necessarily the way forward and that it was the therapeutic relationship with a patient that was important. That is not a criticism of that approach to treatment because the same criticism could be made of many others. It simply is to say that all the time we should continue to develop our understanding and evidence base. We cannot assume that when we have demonstrated something, that is it and we can put it to bed, forget about it and not explore it any further. We need to keep working at it.
It also demonstrates that psychological approaches of various kinds are effective, sometimes remarkably effective. However, it has to be the right treatment, the right training, the right person over the right period and so on, which requires a lot of work and a multidisciplinary and multimodal approach. It requires a number of different approaches to therapy. I mention that at this early stage because I always want to get that out of the way.
One could make certain criticisms but the report had a tremendous effect. It jolted the Government into starting to provide significant amounts of money for training, for bringing people forward and for valuing psychological therapies. Therefore, when the noble Lord, Lord Layard, contacted me earlier this year and said, “John, we have another report coming out”, I was very excited because I knew that the quality of the report would be high, the argument would be persuasive and that it would be done to improve things for our patients, which is the important thing.
When the report was published in June, I was not in any way disappointed. It was all those things. It was concise and clear, and it pointed at the problem in stark terms that many of us who have worked in this area for years found refreshing. Basically, it made the point that half of all illness is mental illness, which was not a surprise because we have always known that. It has a serious degree of morbidity. People’s lives are hugely damaged by mental illness, and there is enormous misery for them and their families. There is a huge cost but there are ways of dealing with these things. In the report, the noble Lord and his colleagues did not deal just with depression and anxiety. They dealt with the whole raft of mental illness, although not particularly with things such as dementia, other more organic disorders and drug and alcohol addiction, which are also important and fall within the wider group.
I was very keen for your Lordships’ House to find an opportunity as soon as possible to ask the Minister what Her Majesty’s Government’s response is to this report, which is the main burden of my remarks. I think that the report is clear and it marks up a number of issues and problems. I am very proud and pleased that the coalition Government have been prepared to give £400 million to increasing and developing access to psychological therapies. However, one of my anxieties is that I keep getting reports that that money is being substituted, and that some psychological therapy services are being closed down and IAPTs are being increased, rather than that IAPT money is coming in. We do not know whether it is adding to the services that are available.
Places such as the Maudsley, St Thomas’, Forest House in Walthamstow and Camden Psychotherapy Unit have provided well trained and good services. It is not a matter of cost because, in some of these services, the therapists coming in are good, well trained and well supervised people who provide therapy for nothing or for very small amounts of money. But it is easier for commissioners to commission one large organisation to provide one approach to therapy, rather than to pick up those who have very often provided all sorts of different approaches to therapy in the communities.
After all the things we went through because we want to see a change in the approach to commissioning, I was particularly sorry to hear that some of the new commissioning groups are simply saying, “We are going to carry on the way the previous commissioners were carrying on and we are not going to change”. If that is true, it is extremely disappointing. I seek reassurance from the Minister that he will monitor this; that he will make sure that the money is not substituted and is extra money for psychological therapies; that it is for the range of therapies; and that there is an understanding that short-term therapies—for example, for people with personality disorders—are sometimes counterproductive. We need to create long-lasting major change for these people because they are very damaged and need input over a period of time. If we do not do that, they will cost a lot more through the criminal justice system. There will also be a transgenerational transmission of their disorders, which we will need to take into account whenever we think about the costs to the community. We need different approaches to treatment that are suitable to these people.
My concern is not about just the therapeutic relationship with people in outpatient therapy. I have been very disturbed to learn that in places such as Rampton, Broadmoor and Ashworth, patients increasingly are locked up at night in wards because there are not enough staff. That is not managing the relationship. I increasingly find reports of young doctors who see a patient only once. The patient is checked in and in no time the patient is out. The young doctor does not even learn how to develop the professional relationship. Indeed, there are managerial relationships which are not very professional and are based on no evidence that they bring a positive outcome in the running of services. If we are talking about an evidence base for the therapy, we need an evidence base for some of the management approaches that have been undertaken, which are clearly and demonstrably not working.
In September, at our party conference in Brighton, I was very pleased that the report from the noble Lord and his colleagues, and the recommendations from it, was warmly and overwhelmingly supported in a motion to the conference. I want warmly and overwhelmingly to support them. There will be some issues, which we will need to explore, including the recommendation that the GPs should get more training in psychological therapies. That is absolutely right but perhaps it should be not only through IAPT teams. Perhaps there should be a bit more of an emphasis on the idea that there might be a range of therapies available.
I am hugely encouraged that we are seeing some espousing of this by the academic community. I trust that the £400 million will be extra money and that it will be added to. I know that the Minister is sympathetic to this but I hope that he will give us a little more than sympathy and reassurance. I hope that he will be able to encourage us as we see this developing over the coming months and years.
Lord Wills
My Lords, I congratulate the noble Lord, Lord Alderdice, on securing this debate on this most important subject. It is a tribute to his work, and to my noble friend Lord Layard and other speakers in this debate, that nowadays this Government accept without question, as did the previous Government, that there is no health without mental health. That is huge progress from the situation just a few years ago.
However, as the noble Lord suggested, there is no reason for complacency. There are formidable challenges ahead. Others noble Lords with far greater experience in this sphere than I have will no doubt speak about those challenges in the rest of this debate. In my few remarks I want to focus on the role of the voluntary sector in delivering mental health services and, in particular, something that might be able to be done to support it.
The voluntary sector has become more and more important in delivering mental health services. We heard a few examples from the noble Lord, Lord Alderdice, of its invaluable work in delivering mental health services and in providing care and support to well over 500,000 people who use mental health services every day across England in a wide variety of community and hospital settings.
The voluntary sector is by nature more heterogeneous than statutory health and social care organisations. It is that very variety that has helped generate much of the innovation that service users value in the delivery of mental health services. But it also makes more demanding the task of supporting it through all the challenges that it faces. I should be grateful for any detail that the Minister can give about how the Government intend to support voluntary sector organisations in the months ahead, with all the difficult challenges of funding that we all recognise. Earlier this year, in a statement of the Government’s intent, a recently departed Health Minister said:
“It is crucial that we continue to champion our voluntary organisations, because their expertise allows them to design and develop innovative solutions to the big challenges we face in health, public health and social care”.
It would be interesting to hear how the Minister intends to continue that theme and support voluntary sector organisations in the months and years ahead.
Among all those challenges that the voluntary sector faces, including the fundamental one of adequate and sustainable funding, it needs to negotiate its way through a thicket of complex statutory provision.
There have been two major mental health Acts in the past 10 years and more than 100 pieces of legislation that might be relevant to those delivering mental health services. That is daunting to work through for anyone, but especially for those operating in the voluntary sector, who often do not have any significant back-up or support at all. That is why it is very welcome that the Mental Health Providers Forum is about to publish a resource that brings together in one place the most commonly used legislation in mental health to show how it relates to policy and practice, as well as to the experience of all those who use mental health services. The Department of Health should be congratulated on its role in funding the development of this resource, which will help practitioners, managers and trustees to combine legally sound decision-making with safe and effective practice. I hope that the Minister can assure me that he and his department will do all they can to bring this resource to the attention of all those concerned.
Baroness Meacher
My Lords, I congratulate the noble Lord, Lord Alderdice, for tabling this important debate; a debate, in my view, of national importance and of particular importance to the Government in their quest to take a million people off employment support allowance, or, in the future, universal credit figures within about 10 years. That is a major objective of this Government. We know that more than 40% of ESA claimants have mental health problems, the vast majority having depression or anxiety. That is nothing new. We also know that NICE recommends improving access to psychological therapies, and CBT most particularly. Not everyone likes the conclusions of NICE, or IAPT, but we have to take seriously the enormous amount of work that NICE does in looking at all the research available on a subject such as this and drawing its conclusions.
I do not share the views of the noble Lord, Lord Alderdice, that the style of therapy does not matter too much and that you can have bits here and there. This is a much more serious matter and people who practice these therapies tell me that these treatments, like other medical or pseudo-medical treatments, are potentially dangerous if they are not done really well. The quality of the therapist is absolutely vital and the methods and the types of therapy that they use. If we want to help people, rather than make them worse, it is no good using the wrong type of therapies, or short-term therapies, with the wrong kinds of people. We have to be very careful. It is essential that these IAPT services are of the best possible quality, which means, of course, using the best possible people. These services need to be available right across the country, so that GPs, wherever they are, can refer people for such help so that they do not lose their jobs—that, surely, has to be the first priority—or, if they have already lost their jobs, so that they can be prepared, as soon as possible, to get back into work and stop claiming benefits.
I shall leave my noble kinsman Lord Layard to talk about the national perspective. I shall talk about what is going on on the ground, as I am familiar with that. One problem is that the tendering process can result in services being provided by two or three different organisations. Far from just giving these services to the NHS, our experience is that they tend to be divided between different organisations. That may be all right but, over the years, health and social services have struggled to ensure that services provided across several organisations hang together and provide a good pathway of care for patients. It is very difficult on the ground; it sounds nice, but it does not work. The second best solution is to ensure that these different organisations work effectively together so that patients have a good pathway.
Competition rules may be being misinterpreted, but commissioners on the ground understand that these different organisations must use different IT systems, even though they are very happy to use the same one. The result is that these organisations do not communicate effectively with each other. That may be due to the limited understanding of commissioners. I do not think that the problem lies with competition, per se; I think it lies within the capacity of commissioners to operate competition in the best interests of patients and, to be perfectly frank, that simply is not happening.
Another issue is the tariff for IAPT services. The “any qualified provider” guidance for commissioners makes it clear that local commissioners should set their own tariffs. We know what happens if they do that. We know that the money supposedly put into IAPT psychological services is not ring-fenced and that local authorities are tempted to siphon it off into other things, and who can blame them? I do not blame them, but it means that we have to be very careful if we want a really good psychological service to deal with the unemployment problems of people with anxiety and depression. We cannot cut corners and a lot of tariffs are being set too low because of a lack of understanding.
The most serious problem, as I understand it, applies to steps 3 and 3 plus services. To treat effectively those with severe anxiety, severe obsessive-compulsive disorders and those with tricky, difficult and often multiple problems we need skilled therapists. That cannot be done by a low-cost therapist. Under AQP rules, a session of high-intensity therapy costs £40 to £50. High-intensity therapists themselves will cost more than that. There are also other costs such as administration, office costs and so on. However, when properly funded, we know from research that these services are highly cost effective; they get people back into work. The big question is why this is happening.
Even if trusts downgraded their intensive therapists from band 7 to band 6, which will inevitably mean losing their very best people—the noble Lord, Lord Alderdice, said, that they should not do that—and even if they made huge and probably unrealistic assumptions about productivity, organisations could not afford these services at steps 3 and 3 plus. My understanding is that steps 1 and 2, although challenging, will be deliverable. The whole benefit of the IAPT programme is that it is a stepped care programme. If someone is identified as needing step 2, and after a bit the therapist realises that that person has much deeper and more extensive problems than they originally presented with, they will need step 3 and if step 3 is not there, the value of step 2 will be lost. Such people will not get better and they will lose their jobs or not get back into work. That is the sort of concern felt at the bottom, where people are trying to deliver these services. I am not saying that they should all be delivered by the NHS. The NHS is having to renegotiate contracts and is having to cut the amount of money to deliver the same service, or something nearly as good. However, with IAPT it is not like that; it will all be tendered out, and change will be much more radical.
The view that I have had from others is that this consequence is more of a cock-up than a conspiracy. People are not trying to destroy this, but these AQP services will go live in November 2012 through to March 2013. The consequences of all these inadequate tariffs and problems on the ground, separating the different bits of the service across organisations, will become apparent during that six-month period and will get worse over time.
Before I finish I want to refer to a rather nice little piece of information, which supports my concerns. I happened to be at the Verulam School in St Albans talking about the House of Lords last Friday. The sixth formers were an impressive group of people. They were so concerned about mental health among young people—that is, themselves—that they undertook a survey of 1,800 young people in the St Albans area, which is not known for its deprivation. They really got at some of the problems and concluded:
“The value of mental health provision and the overwhelming need for it has become clear to us, as has the need for appropriate access and early support”.
They were very concerned about cuts to counselling support services for young people in St Albans. If you go along to east London you will find that things are even tougher, but it was interesting to find that result in a relatively well heeled part of the country.
I appeal to the Minister to do all that he can to rescue this inexpensive and highly cost-effective contribution to the Government’s goal to reduce unemployment. Will he try to ensure that IAPT is removed from the AQP system, if at all possible, even at this late stage? Will he try to secure the continuity of the central policy unit for IAPT? Those two things would transform everything. I have great trust in the Minister and look forward to hearing his comments.
Lord Layard
My Lords, I, too, am grateful to the noble Lord, Lord Alderdice, for securing this debate. I declare my interest as a national adviser to the IAPT programme and chair of the group to which the noble Lord, Lord Alderdice, referred.
We are now at a critical juncture in relation to the IAPT programme. On the one hand, we have some wonderful features. We have the Government’s commitment to parity of esteem for mental health, which is very important. For the out-service we have the Government’s commitment to providing treatment in 2015 for 15% of the 6 million people suffering from depression or anxiety disorders, which is a very important commitment. As part of this, the Government have also committed to training 800 therapists a year over a three-year period.
The issue is what is happening on the ground. Up to 2011, the programme was an extraordinary success. Starting from scratch it reached, within three years, 10% of those 6 million people. That is extraordinarily good going from a standing start. This is not a service that was being modified; it was created in a vacuum, which was a really major achievement. Equally, on the training side, 3,400 therapists were trained in evidence-based therapies, using a state-of-the-art national curriculum developed by the central team and its experts. The outcomes were also good. Recovery rates approached 50%, which was the target, and the programme has been extraordinarily successful in measuring the outcomes of its patients. In fact, it has accumulated the largest body of patient-reported outcomes, physical or mental, in the whole of the NHS.
All these achievements have been brought about by the fact that there was a central leadership with good administrators and a good network of experts co-ordinated within the Department of Health and by the extraordinary contribution and self-sacrifice of the outstanding clinical director, Dr David Clark—I must mention that because we have been extraordinarily privileged to have perhaps the world’s leading clinical psychologist leading this programme. It is therefore not surprising that the world’s leading scientific journal, Nature, last week acclaimed this as a world-beating programme. People all over the world are looking to it to see if it can continue developing.
However, although the programme is only half way through its development phase, its future is already in doubt and, as I mentioned, the Government are at serious risk of not achieving their commitments for 2015. In 2011-12 there were 530 training places, not the Government’s commitment of 800, and numbers are looking even more precarious in the present year. Services for patients are not expanding, as would be required to get from 10% to 15%, but are being cut in some localities and are standing still in others. At the same time, waiting times in IAPT are rising.
Also increasing is the problem, which was just referred to, of commissioners focusing, through their financing arrangements, more on those who need the least help—the easiest to help who can be dealt with cheaply. There is a serious dead weight if you give the help to the people who least need it. That will increasingly go on under these financial pressures unless serious steps are taken to stop it.
What can the Government do? As the services are locally commissioned, the Government have no way to force local commissioners to spend the money that was set aside in their baseline for IAPT in the spending review. They do, however, have tools, the first of which is the central guidelines embodied in the NHS outcomes framework. This is what commissioners read. They cannot read all that paper and prose but they can read the one sheet that contains 60 outcomes for the NHS. Where does IAPT appear in those 60 outcomes? It does not. That is just not good enough.
Depression is 50% more disabling than most of the chronic physical illnesses that are now a big focus for the NHS. Depression and anxiety account for at least one third of all morbidity in Britain. The NHS is there to deal with the mass of morbidity in the country, so how can it possibly be that the main treatment for those conditions is not in the NHS 60 outcomes? I agree that this is not a conspiracy, but it is a failure which happens because mental health so often gets overlooked. Unless we have IAPT outcomes within the NHS outcomes framework, it is nonsense to be talking about parity for mental and physical illness.
We have waiting time targets for all physical conditions treated outside general practice, but there are no waiting time targets for depression and anxiety. That is not parity of esteem either. There is also a huge problem with local commissioners paying less and less for therapy, leading to a bias against those in greatest need. We need a central initiative and national tariffs if we are to secure parity of esteem for serious mental illness as against physical illness.
I must come, finally, to the question of the central leadership of the programme, which is, as I explained, why it has succeeded. The programme is only half way through its development but its present coverage is 10% compared to the 15% to which the Government are committed. Even then, the programme will not have touched most of the 3 million people with physical conditions who are also mentally ill. This problem has not yet been tackled, although it is costing the NHS a huge amount in the physical healthcare budget due to the comorbid mental condition. The estimate is that something like £10 billion a year of the NHS physical healthcare budget relates to comorbid mental conditions that ought to be treated. Big savings could be made from that. We claimed in our report that at least half a billion pounds could be saved by extending psychological therapy to that group. Extending IAPT on that scale would cost the NHS nothing in net terms. On top of that, it would save the DWP and the Treasury the money on benefits, which would again repay the cost of the therapy. However, none of this will happen without central leadership. It really is just like that. The question is: what is being planned for the central leadership of the programme next April, when it ceases to be housed in the Department of Health? So far, we have had no public word on that critical question.
There is a real risk of a disaster in the making, not intentionally but by mistake. I have to ask the noble Earl three questions—not to embarrass him, because I know his heart is in the right place. However, I get heartrending letters from people every week and there are millions of people out there whose lives are at stake in all this. If I might, I should like to end with the three questions. First, what plans do the Government have for the central IAPT leadership team? That really is crucial. Secondly, will the IAPT outcomes be incorporated in the outcomes framework? Thirdly, will the Government introduce rights to waiting times in mental health as in physical health? I hope that the noble Earl can help us on all these points, either today or shortly hereafter.
Baroness Tyler of Enfield
My Lords, it is always daunting to follow someone as eminent as the noble Lord, Lord Layard, in a debate on mental health, but that is what I will seek to do.
Like many other noble Lords this evening, I very much welcomed the Government’s mental health strategy, No Health Without Mental Health, which gave clear priority to a long-neglected area of health policy. The implementation framework for that strategy, which was published earlier this year, was equally welcome in ensuring that the strategy did not simply gather dust. Like my noble friend Lord Alderdice, I greatly welcome the £400 million that the Government have invested in improving access to psychological therapies—IAPT—as a key plank of the strategy.
While I am pleased that the NHS Commissioning Board has endorsed the framework, it is also vital that the board makes the implementation of the strategy one of its key priorities. Like the noble Lord, Lord Layard, I think that means that it should feature prominently in the commissioning board’s mandate and the NHS outcomes framework. I ask the Minister to update, and I hope assure, the House on that point.
However, even that will not be enough to make a reality of improved mental health services for all. More is needed and I want to pick out three things. First, the forthcoming changes in the commissioning arrangements give the potential for a greater focus on early intervention. This means commissioners in CCGs and the national commissioning board having access to the right level of mental health expertise, both to assess mental health needs and to commission the right services to meet those needs.
Secondly, the Government have stated their intention to introduce payment by results for mental health services. The first step here is the long-awaited development of tariffs for mental health services. I know that those involved in the development of tariffs have expressed concerns about the lack of clear guidance from the Department of Health and in some cases poor data and inadequate IT systems at a local level. This does not augur well. I think that the sector as a whole recognises the challenges that payment by results represents for the whole mental health system, but can the Minister update the House on what additional support the department is making available in this complex area? Thirdly, with the expansion into mental health services of payment by results, we also need to ensure that the outcomes for which providers are paid fit with the objectives of the mental health strategy and are aligned with NICE’s work on quality standards. In other words, it must all join up.
We all know that mental ill health cannot be tackled by NHS mental health services alone. It is crucial that others—we have already heard about them this evening: local authorities, employment, housing, and criminal justice—play their part. The new health and well-being boards will be vital in helping local government, the NHS and others, including the voluntary sector, to tackle the causes of ill health at source. I look forward to seeing well-being services set up, which would include occupational health, housing, smoking cessation, fitness centres and mental health services working together for new attitudes towards public mental health.
Like others, I mentioned the importance of IAPT at the beginning of my speech, and I recognise that we have already heard some differing views on this tonight. While I am a great supporter of the concept of talking therapies, my view is that the current policy does not adequately or accurately reflect the importance of providing a range and choice of counselling and psychotherapy to meet a range of needs. I recognise and welcome the limited expansion of IAPT from purely CBT models to include other models such as couple therapy for treating anxiety and depression in cases where relationship problems are also a factor—either a cause or a consequence of the depression.
However, specialist providers, particularly those in the voluntary sector, have found it very difficult to navigate their way through an IAPT commissioning process that was clearly designed with the statutory sector in mind—a point that I thought was made very compellingly by the noble Lord, Lord Wills. I believe that counselling and psychotherapy play a vital role in promoting good mental health and well-being, and in the treatment of mental ill health. In my view, current government policy still does not sufficiently reflect the role that counselling and therapy can and do play. I would like to see more collaboration and joint working in this area.
Finally, I draw attention to the importance of improved mental health services for children and young people, for if mental health services have long been seen as the Cinderella of health services generally, surely children’s mental health services are the Cinderella of that Cinderella service. Yes, the role of the NHS is crucial here, but so too is the role of schools and the voluntary sector.
We all know of the parlous state of the NHS Child and Adolescent Mental Health Services, known as CAMHS. In a recent survey of providers and commissioners conducted by YoungMinds, over half of respondents said that they intended to reduce their spend this year. The biggest cuts were in local authorities, with some slashing up to 25% from their budgets. On a more positive note, some 20% said that they were planning to increase their funding for CAMHS. All this can only exacerbate the existing, very large variations in availability, quality and timely access to these vital services. On top of these, many voluntary sector services, as we have already heard, are having to cut back or close down.
I welcome the new bond initiative funded by the Department for Education to increase the availability, quality and young-person focus of early intervention services that address mental health issues earlier. However, this is currently a limited pilot in five local authority areas. Equally, I welcome the new children’s IAPT pilot, again in a small number of areas. I ask the Minister what plans the Government have for rolling this out more widely.
Touching on a point made by the noble Baroness, Lady Meacher, while thousands of young people in Wales and Northern Ireland benefit from national programmes of school-based counselling, England lags behind as the only country without a commitment to these services. This leaves many young people in England without effective and accessible therapeutic support in schools, despite the fact that counselling is associated with significant reductions in psychological stress. The Welsh Government’s national school-based strategy, which has been externally validated, has been shown to be an overwhelming success, so much so that the Welsh Government are planning to make counselling in Welsh secondary schools a statutory service. With the clear benefits that it has demonstrated in improving attendance, behaviour and attainment in schools, surely providing access to school counselling could be one good use of the pupil premium in England.
Why have I made such a great play of children and young people’s services? Research has shown that huge costs to the economy are associated with mental health problems, which all too often begin in childhood and continue into adulthood. Perhaps I may give noble Lords a few facts. Half of all lifetime mental illness presents by the age of 14, contributing to the vast economic and social costs of mental health problems. One in 10 children under the age of 15 has a diagnosable mental health disorder. Rates of mental health problems among children increase as they reach adolescence. Between one in 12 and one in 15 children and young people deliberately self-harms. More than half of all adults with mental health problems were diagnosed in childhood, but—this is the crux of the matter—fewer than half were treated appropriately at the time. According to the then Department for Children, Schools and Families in 2009, 60% of children in care have some form of mental health disorder. This is an astonishing figure that calls for an urgent response.
In summary, mental health problems obstruct many key goals for children. I would welcome the Minister saying what more the Government are doing to join up policy effectively, particularly between the Department of Health and the Department for Education, in order to address the mental health problems of children and young people. It is a no brainer that we must do this. It makes sense socially, economically and morally.
Baroness Young of Hornsey
My Lords, like other noble Lords, I thank the noble Lord, Lord Alderdice, for introducing the debate this evening. I am sure that we will all acknowledge that although some progress has been made in this area, there is still an awful lot of work to be done. No doubt we will return to this subject in the years to come.
I am very glad that the noble Baroness, Lady Tyler of Enfield, spoke so much about children and young people. This is a point that I, too, will make. She also raised the issue of the implementation framework for the mental health strategy for England. That is another area I will touch on this evening. As the noble Baroness stated, we need to do much more to build good mental health and resilience among children and young people from birth through to adulthood. At the other end of the scale we also need to address the challenges faced by an ageing population, with an increasing number of older people experiencing significant mental health problems, including but not exclusively dementia. As always, I am afraid that there is still a substantial job of work to be done to ensure that ethnic minority service users are treated fairly.
The content of the implementation framework has been well received. However, there is no statutory backing, and it is phrased only in terms of what local health and other bodies, including the voluntary sector, “might” rather than “must” do. At this time of severe spending constraints in the NHS, will the Minister explain how his department intends to ensure, first, that the NHS across England acts on the implementation framework; and, secondly, that non-NHS organisations, too, which are crucial to the success of the strategy, act on the framework? As the noble Lord, Lord Wills, mentioned, that will include ensuring proper support and proper mechanisms to enable the service to be of the highest quality.
An increasing body of evidence shows that children and young people can develop mental health problems from a very early age, and that these problems, if not addressed quickly, and effectively, have a higher risk of developing into adult mental illness. Most adolescent and adult mental illnesses can be traced back to childhood. Therefore, there is an urgent need to focus on children’s early years, for example through building parenting skills and providing support to vulnerable families with young children. In addition, schools have a crucial role to play in building children’s emotional well-being, especially given the link between mental health and academic achievement.
Although for clear reasons we focus on mental ill health, we should also look at how we understand mental well-being and how we can encourage and develop and make sure that that works, in order to pre-empt instances of mental ill health. I would like the Minister to acknowledge the importance of children’s and young people’s mental health, and outline the department’s proposals for increasing support for parents and families, particularly with young children, in vulnerable situations. I reiterate what the noble Baroness, Lady Tyler, said about children in care being at very high risk of developing mental ill health both while they are in care and subsequently.
The Mental Health Foundation project, Age Well, is a two-year inquiry funded by the Esmée Fairbairn Foundation. We have been looking at the factors affecting the mental health and well-being of the generation of people currently aged between 55 and 65—the so-called baby boomers—as they get older. I have been privileged to chair the panel of inquiry that will be publishing its report on this subject shortly. The rationale for conducting the inquiry was that people born between 1946 and 1955 are now growing older and moving into a life-transition period. Growing older, of course, brings challenges that are different from those faced in earlier phases of life.
Evidence shows that the experience of mental illness in later life is often underrecognised, underrated and inadequately treated. Risk factors for mental ill health for the cohort include bereavement, the disabling effects of chronic conditions, pain, the effects of being a carer, loneliness, social isolation and so on. Protective factors include—and this relates to mental well-being—social ties, connectedness, intimate relationships, friendship and engagement in social activities. Good self-esteem and self-reliance can also buffer people against difficulties.
A major factor in population ageing is survival against premature death; fewer people in the 1946-1955 group have died in childhood, young adulthood or middle age, but the evidence is that they may not be much healthier than previous age cohorts as they grow older. Inequalities have been growing in the UK population since the 1980s. This is shown in a range of outcomes, including experience of illness and poor mental health. There is a need to focus on protecting those who are most likely to be at risk for poor mental health and experiencing mental illness.
These are some of the key findings that we have uncovered and had witnesses speak to us about so far. We would like to be assured that the Minister and his department are fully aware of and are equipped to deal with the implications for our ageing population of mental ill health and promoting mental well-being.
The Mental Health Foundation and Age UK hosted an expert seminar earlier this year on mental health among older people. There were a number of key messages from that group. I am not going to go into them all now because there is a report available. However, there is no doubt that the NHS reforms have created a period of great uncertainty and that everyone interested in older people’s mental health needs to keep pressure on the reorganised NHS, public health and local authority bodies to work together to plan and commission a suitable range of support for older people.
Another crucial issue for the mental health services must be ethnic minorities’ experience of the mental health system; people of African Caribbean descent in particular are still being prescribed stronger medication, are more likely to sectioned, and, at least in London, are more likely to be referred to the mental health services by the police. Can the Minister tell the House about specific mechanisms for engaging with this issue and when we might expect to see some improvement in an area that has long dogged the mental health services?
Baroness Emerton
My Lords, I, too, thank the noble Lord, Lord Alderdice, for raising this important debate. Yesterday morning I was listening to Radio 4 and was somewhat taken aback when they said it was mental health week. A church service was being relayed from Epsom, I think, where there had been a great cluster of psychiatric hospitals. I really did not know that there was such a thing as mental health week, so I confess my ignorance. The Government had a No Health Without Mental Health strategy. I would add, no health without mental health, patient well-being, public health and physical health; in other words, a holistic care pathway.
I am a retired nurse and also a mental health carer. I concur wholeheartedly with the other speakers, particularly the noble Lords, Lord Alderdice and Lord Layard, about the benefits of psychological treatment and also how scarce it is. I say that with very definite first-hand knowledge—the scarcity is having an effect on the person I care for.
Much has been achieved in the provision of mental health services, but against the current situation of economic austerity and consequential cutbacks we are seeing areas where services are definitely suffering. I can give an example. Recruitment to mental health care nursing programmes is excellent, but the cutbacks in student numbers will have a long-term effect on people’s readiness to come into nursing as registered nurses. Already the CQC has recorded that the situation has led to an increase in support workers to fill the gaps left by registered nurses. This is a false economy as the evidence is clear that if the ratio of registered nurses to support workers decreases, the quality of care delivered is affected. Can the Minister say whether the Government will address the long-term effect of reducing the student intake and the adverse effect on patient care, and that the reduction of the ratio of registered nurses to support workers will be re-examined? Further, will the support worker training programme become a mandatory training programme, not leading to a voluntary register? I know that the noble Earl will not be surprised to hear me say this yet again.
Implementing the holistic care approach will be assisted by the Nursing and Midwifery Council. The care standards it is introducing are to be implemented in November this year in all universities preparing nursing students in all specialties to gain 50% theory and practice in each. This is further assisted by the Chief Nursing Officer’s recently published vision of developing a culture of compassionate care. The values and behaviours of the vision are that at its heart are what are described as the “Six Cs”—compassion, care, competence, communication, courage and commitment.
However, as has already been mentioned by several speakers, there are still many barriers between the different professional groups: the NHS, local authorities, the third sector and the independent sector; they all need to be broken down. This requires a special kind of leadership that can effect change through not only a detailed knowledge of each organisation and how it works, but also the personal leadership qualities of persuasion and influence. This needs to be recognised within a defined government strategy with a given time-span. When the large psychiatric and mentally handicapped, as they were then, learning disability institutions were closed, there was a clear strategy with a timetable to address the situation. Many speakers have referred to the outcome framework, and surely something could be built into it. That would provide a definite target date for working towards a cohesive service and, in turn, it would allow for the development of the holistic care pathway.
Mental health services present a complex field of practice with an enormous plurality of providers and stakeholders. Added to this are the demographic profile of an ageing population and workforce, and a loss of experienced practitioners due to the financial cutbacks. Against this background, commissioners of services call for strong leadership that understands the complexity of conditions and has the sensitivity to know that providers are equipped to deliver high quality services. Would the noble Earl consider that there might be an opportunity for the Government to highlight the need for such leadership qualities and build this into the policy requirements? In the absence of high quality leadership, the culture of mental health services will deteriorate, leading to a fall in the quality of practitioners and the services provided, along with a lowering of standards. Can Her Majesty’s Government allow that to happen to this very vulnerable group of the population? I think not.
Lord Patel of Bradford
My Lords, I too add my thanks to the noble Lord, Lord Alderdice, for tabling this important and timely debate. The noble Lord has made and continues to make an immense and important contribution to this area of healthcare in terms of its development and delivery. Like him, I believe passionately that we must do a great deal more to address the needs of people who suffer from mental health problems.
The question before us today is how do the Government intend to strengthen the provision of mental health services in the NHS? It is a vital question at a time when the NHS is facing the most significant upheaval in its entire history and the finite resources we have for healthcare are being further reduced.
When the coalition Government first came to power I was very pleased to see mental health given priority attention. Those earlier efforts to raise the profile of mental health problems were very much welcomed, in particular their strategy No Health Without Mental Health, although I think I prefer the title of the noble Baroness, Lady Emerton. The Government have continued to invest in talking therapies and we have seen the excellent anti-stigma campaign Time to Change. However, I have to ask myself what is really changing? What lies beneath all the rhetoric and good intentions? The problems are certainly not getting any less.
My noble friend Lord Layard talked about his recent report published by the London School of Economics that sets out some of the starkest evidence that I have seen that the problems are getting worse. More significantly, as we see increasing levels of problems, we do not see a similar rise in treatment services. The report clearly outlined that mental illness is now nearly half of all ill health suffered by people under 65 and it is more disabling that most chronic physical disease. Yet, only a quarter of those involved are in any form of treatment. Mental illness also accounts for 23% of the total burden of disease. Yet, despite the existence of cost-effective treatments, it receives only 13% of NHS health expenditure.
There are currently six million people with depression or crippling anxiety conditions, and more than 700,000 children with problem behaviours, anxiety or depression. The noble Baronesses, Lady Tyler and Lady Young, raised the important issues with respect to these children. However, most of these people receive no treatment because, as the report says:
“NHS commissioners have failed to commission properly the mental health services that NICE recommend”.
The report concluded:
“The under-treatment of people with crippling mental illnesses is the most glaring case of health inequality in our country”.
It is a shocking form of discrimination because effective psychological treatments exist but are still not widely enough available. What steps are the Government taking to address this health inequality and to ensure that local authority and NHS commissioners do commission mental health services in line with NICE recommendations?
It is very clear that we cannot allow this situation to continue. At a time when the economy continues to struggle it is vital that these issues are addressed, because the lack of adequate mental health provision is threatening the chances of our economy recovering. For example, recent research shows that one in 10 workers has taken time off work because of depression. The MORI poll that identified this figure was conducted across seven European countries involving more than 7,000 people. Overall, 20% of those polled had received a diagnosis of depression at some point in their lives and, shockingly, the highest rate was in Britain, where 26% had been diagnosed. Among workers experiencing depression, 58% in Britain were most likely to take time off. Surely, in view of these facts, the Government need to rethink cuts to mental health care and should be looking to expand care instead.
Notwithstanding the comments made by the noble Lord, Lord Alderdice, about therapies, evidence has shown that the cost of psychological therapy is low and recovery rates are high. Expenditure on psychological therapies for the most common mental health problems is also cost effective as long as we take heed of the comments made by the noble Baronesses, Lady Meacher and Lady Tyler, about the need for consistency, quality and choice of services. For example, when people with physical symptoms receive psychological therapies, the average improvement in physical symptoms is so great that the resulting savings on NHS physical care would outweigh the cost of psychological therapy—a point made clearly by my noble friend Lord Layard.
It was for these reasons that the Labour Government started in 2008 the six-year IAPT programme. We know that in areas where this has been effectively commissioned, it has had a positive impact. However, we also know that the £400 million earmarked by the coalition Government for psychological therapy has not always been used for its intended purpose because there was no commitment on NHS commissioning managers to do so. It is essential that that programme is completed as planned, since even this will provide for only 15% of need.
What about those with more complex and enduring mental health problems? Let us not forget that when we are talking about strengthening NHS services, this includes services provided in prisons, where we know there are very high numbers of people with mental health and substance misuse problems. In fact, the annual report to Ministers by the independent monitoring board at HMP Pentonville reported that health and social care workers providing health support to inmates are being stretched by a “serious and sharply increasing” rise in demand for care. The report stated that mental health teams at the prison received 24 referrals a week in 2011-12, up from 18 a week the year before. Incidents of self-harm had also increased “very significantly” over the past year. The prison’s 22 in-patient beds, the majority of which are used for mental health patients, were full to capacity. The report said that the reasons behind the spike in mental health demand at the prison were “not fully understood”, and warned that,
“further resources are urgently needed to tackle these issues”.
What will the Government do in response to this report to address the urgent health service resource needs in prison to tackle complex mental health issues?
When we are talking about vulnerable groups, we know that people from black and minority ethnic communities face specific difficulties, including higher rates of mental illness in some groups and problems with access to the right care and treatment—issues raised by the noble Baroness, Lady Young. Service user groups have expressed fears that funding provided to local user-led mental health groups, where some of the best progress has been made in black and minority ethnic mental health service user involvement, may especially be vulnerable when services are looking to make significant economic savings.
I share these concerns especially in light of the establishment of more generic service user involvement mechanisms such as Healthwatch England and local Healthwatch organisations. These cannot and must not be seen as a replacement for involvement mechanisms especially for mental health service users, and especially not for those that engage black and minority ethnic communities and have a rights-based focus capable of addressing issues in relation to the use of compulsion under mental health law. What specific steps are the Government taking to ensure that vital local user-led mental health groups are being maintained alongside Healthwatch and not being replaced by them?
In conclusion, it has been said that the challenge of mental health should be placed at the heart of Government but I suggest that where it really needs to be is at the heart of the new commissioning structures within clinical commissioning groups and local authorities. But as the NHS has clearly failed to commission mental health services in line with official guidance, and with further pressures to come on the whole NHS budget, will commissioners be able to take the action that is needed on securing and developing mental health services? I greatly fear that mental health services will continue to be the Cinderella services and that the urgency of need and the benefits that can be realised are not fully understood within these new and as yet untested commissioning structures. My final question to the Minister is: what will the Government do to ensure that clinical commissioning groups and local authorities address the full range of needs for mental healthcare in their commissioning plans?
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by congratulating my noble friend Lord Alderdice on securing this debate, and on raising the important issue of strengthening mental health in the NHS.
This is a timely debate. Wednesday is World Mental Health Day, a day which sends an important message across the global community: mental health is everyone’s business. As the noble Baroness, Lady Young, rightly emphasised, it is appropriate to turn the spotlight on mental health services at a time of huge structural and service reform across health and social care, when a lot of the attention has been focused on primary care and clinical commissioning groups. It is vital that mental health is woven in to the fabric of these reforms.
Before I respond in detail to the remarks made by my noble friend and other noble Lords, I want to take this opportunity to thank him and the noble Lord, Lord Layard, in particular for their lobbying, research, advice and support, which have done so much to set the standard for mental health services and drive system reform.
The recent report from the London School of Economics’ Centre for Mental Health, How Mental Illness Loses Out in the NHS, makes a compelling case for prioritising investment in mental health services and for treating mental ill health as seriously as physical ill health. Although we take issue with some of the content, we are in full agreement on these two central tenets of the report. Mental health simply cannot be an add-on or an afterthought. It costs £105 billion per year, to say nothing of the emotional toll that it takes on individuals, families and carers, so it must always be in the foreground when we think about health and social care. The messages are clear from people with mental health problems and their carers. They want to see a real difference in the range, quality and choice of services available. They want everyone to benefit from our mental health strategy, “No health without mental health”. This includes people with severe and enduring mental illness, those from minority ethnic communities and individuals who have offended.
They also want us to recognise the importance and expertise of family carers, who have so long occupied a shadowy position ill-served by legislation. This Government have committed themselves to fulfilling those wishes. Our new mental health implementation framework, coproduced with five leading mental health charities, sets out how we will do that. The framework translates the strategy’s vision into practical action for specific organisations. It outlines what the new health and care system will mean for mental health; and it shows how the mental health strategy fits with the three outcomes frameworks for the NHS, social care, and public health, and how each will help to deliver the other.
On top of that, the draft mandate to the NHS Commissioning Board, published for consultation on 4 July and mentioned by my noble friend Lady Tyler among others, also emphasises the importance of a new focus on mental health. This is reflected both in a dedicated objective on mental health, and in objectives for improving performance against the NHS outcomes framework. Overall the mandate suggests a culture-change on mental health throughout the NHS.
I simply say to the noble Lord, Lord Layard, that the Commissioning Board is discussing future arrangements with Ministers, but in the end, as he will recognise, it will be up to the Commissioning Board to deliver its commitments, and not for the department to second-guess the board. The noble Lord, Lord Layard, has said that the outcomes framework contains almost nothing on mental health. This is simply not the case. The 2012 framework contains three improvement areas which relate specifically to mental health—
Lord Layard
I was referring only to it containing nothing about the outcomes from IAPT, which is a very big service. There is nothing about recovery from depression and anxiety.
Earl Howe
I am grateful, and I will come on to that point. It is just worth rehearsing that there are three improvement areas: premature death in people with serious mental illness, the quality of life of people with mental illness, and the experience of healthcare for people with mental illness. In addition, many of the indicators relate to all patients and therefore apply equally to mental health patients. We are keen to strengthen the outcomes framework in relation to mental health in general, and recovery from mental illness in particular. We have recently begun work to define what good recovery from mental illness looks like, recognising that for some people this will mean the effective management of symptoms rather than a cure, and to develop proposals for how this might be measured. Our aim is develop measures that are suitable for inclusion in the NHS outcomes framework.
I know that some, like the noble Lord, Lord Layard, have been concerned that not enough is being done to meet the needs of people with long-term physical health conditions who also have mental health needs. We are addressing that. One of the measures by which we will gauge the success of the NHS Commissioning Board will be its ability to improve care for people with long-term conditions. This obviously includes people who have both physical and mental health problems.
Moving on to IAPT, we are also addressing the criticism that psychological services are too difficult to access in the first place. The operating framework for the NHS in England clearly states that the NHS should carry on expanding access to psychological services as part of the improving access to psychological services or IAPT programme. The noble Lord, Lord Patel of Bradford, said that change on the ground was hard to discern. The coalition Government have overseen a big increase in the number of people benefitting from IAPT services: 528,000 people entered treatment in 2011-12, more than double the number in 2009-10.
These new services are achieving recovery rates of more than 40% and are on track to meet recovery rates of at least 50%. We are investing £32 million this year in training new therapists to meet the demand. More than £400 million will be channelled towards talking therapies so that adults with depression and anxiety across England can get access to NICE-recommended psychological therapies. That investment will also help to fund the expansion of psychological therapies for children and young people—I shall say a bit more about that in a moment. We are also looking at how older people, carers, people with long-term physical health problems and those with severe mental illness can get better access to evidence-based psychological therapy.
Contrary to the statements quoted by the noble Lord, Lord Patel, we have no evidence of underinvestment by the NHS in IAPT services. On the contrary, funding is going up. At present, 149 out of 151 PCTs commission an IAPT service, which is nearly 100 services across England covering more than 95% of the population. However, in order to secure consistently good services, there needs to be a fundamental change in the way our society views mental health. Both individuals and organisations need to change some views that on occasion are deeply entrenched. We have commissioned the Royal College of Psychiatrists to look at how we can encourage everyone to ascribe the same importance to mental health and physical health. The work involves many leading royal colleges, professional associations, charities and others. It includes concrete examples of positive changes that parity would help to bring about. The college has already begun to collect and develop examples of both good and bad practice, and its final report will be available shortly.
My noble friend Lord Alderdice mentioned skills. It is important to note the influence that the royal colleges can wield in improving mental health services. The Royal College of General Practitioners has identified improved care for people with mental health problems as a training priority. It has proposed enhanced training for GPs, designed to increase clinical, generalist and leadership ability. I welcome its suggestion that mental health should be a central part of that enhanced training.
The GP curriculum and examination system will be changed to accommodate the new system of training, so we can look forward to newly trained GPs with an extremely broad knowledge of mental health issues. That is an excellent example of the role that groups outside government can play.
There have been a lot of stories about spending on mental health services being cut, but spending on mental health has stayed broadly level in cash terms. Although this has meant a very slight reduction when compared with inflation, this is quite an achievement given the huge cost pressures on the NHS and quite a different picture from the one that is often claimed.
My noble friend Lord Alderdice and the noble Lord, Lord Patel, questioned how we know that the £400 million is being spent on IAPT. The NHS is accountable to the department for results, not for spending money in line with predefined pots; it is outcomes that count. We have made sufficient money available to the NHS to maintain the expansion of IAPT. We have made very clear what results we expect from that investment, but local commissioners must be in a position where they decide how to use their budgets to meet the health needs of their local populations. That is not something that we can decide in Westminster.
The noble Lord, Lord Layard, and the noble Baroness, Lady Emerton, spoke about the slowing down of this effort. Preliminary figures for the first quarter suggest that the expansion of talking therapy services is slowing in some parts of the country. We are looking at the data to make sure that we understand whether that is temporary or something more serious, but it is clear that the picture is very variable across the country.
I have just received a note to say that my time is running out. I say now that I will write to all noble Lords whose questions I have not covered, but I shall in the time available cover as many more as I can, in particular on children’s services, which was a theme of my noble friend Lady Tyler and the noble Baroness, Lady Young.
Children’s mental health is a priority for this Government. The Government’s mental health strategy takes a life-course approach, recognising that the foundation for lifelong well-being is already laid down before birth and that there is much we can do to protect and promote well-being and resilience through our early years and adulthood. We have invested up to £54 million over the four years from 2011-12 to 2014-15 in evidence-based practice, such as children and young people’s IAPT, undertaken work to introduce payment by results for CAMHS, which my noble friend Lady Tyler referred to, and announced plans for a children’s health outcomes strategy.
Children and young people’s IAPT is a service transformation project for CAMHS, extending training to staff and service managers and embedding evidence-based practice across services to make sure that the whole service, not just the trainee therapists, use session-by-session outcome monitoring.
My noble friend Lord Alderdice and the noble Baroness, Lady Meacher, questioned whether there was a bias towards IAPT to the detriment of other services. Although I agree that there are different approaches to providing psychological therapies, it is local commissioners and not central government who are responsible for determining which services should be funded. I am happy to write on that theme, about which I have further information—as I do about charities, a point raised by the noble Lord, Lord Wills, who also asked me about the mental health legislation resource. I have a note that I would gladly have read out, but time has eluded me. I will also gladly write to the noble Lord, Lord Patel, about prisoners’ mental health and to my noble friend Lord Alderdice about patients being locked in at night at Broadmoor, as well as any other points that I have not covered. I am very grateful indeed to all noble Lords who have spoken in what has been a most illuminating and helpful debate.