Mental Health (Cambridgeshire)

Wednesday 10th December 2014 Westminster Hall

16:00

[Dr Julian Huppert (Cambridge) (LD)]

It is a pleasure to serve under your chairmanship, Dr McCrea. I am delighted to have secured this debate on a key issue for my constituents: health care and in particular mental health.

Our national health service is something to be proud of, the brainchild of a great Liberal, Beveridge, and brought into being by the pioneering Labour Government after the second world war. It is an amazing institution, providing care for all of us, free at the point of use. I pay tribute to the excellent and tireless work of NHS staff—and incidentally, I hope the Government will ensure that they are paid appropriately, because independent pay recommendations should be honoured.

Our NHS is, however, not perfect and is under strain. During debates when it was established, the predictions were that it would run more cheaply every year as people became increasingly healthy. In fact, the opposite has happened. People live longer because we are learning to treat more and more conditions, but that costs us more and more. Demand grows rapidly, the range of things we can do increases and NHS inflation outstrips standard inflation, leading to huge cost pressures. Much of the solution lies in preventive measures, because it is of course cheaper to keep people healthy than to treat them when they are not, but we never spend enough money on that as it is so often needed for treatment.

Some areas are shamefully neglected. Mental health in particular has always been left behind. A lot of that is a product of historical, outdated social attitudes—questions of shame, how people ought to be and what was “normal”. Indeed, many believed that mental health problems were a deficiency of character. That is of course rubbish, and I do not think anyone in the House would share such a view today. Nevertheless, a stigma that simply should not be there is still attached to mental health conditions. People are not prepared to talk about mental health, to admit problems or to seek help.

The stigma not only causes anguish for many people and their families, but materialises in discriminatory policies. For example, when the previous Government introduced waiting times in our NHS—arguing, perfectly reasonably, that that would improve provision for cancer patients and mean they were not left waiting for treatment—the Government did not include mental health. It was almost taken for granted that mental health delays were less important than physical health ones. Funding bodies reacted, pulling more money away from mental health in order to hit the new targets in physical health, which was an understandable reaction.

I am glad that that policy era is over. We have now legislated for parity of esteem between physical and mental health. Thanks to the excellent work of the Minister of State, Department of Health, my right hon. Friend the Member for North Norfolk (Norman Lamb), we are introducing the first ever waiting-time standards for mental health next year, described by charities as a watershed moment, although far too late in coming. Other improvements include the recent provision of £150 million to tackle eating disorders, but we have to go much further, because people are suffering and simply cannot wait.

On Saturday, I was at the wonderful Mill Road winter fair. We had a Lib Dem stall, where we were asking people to come and talk to us about mental health, to get some information and to sign a petition supporting our call for an extra £500 million for mental health, which I reiterate today. Huge numbers wanted to sign—many people care about the issue—and we raised lots of money for Centre 33, which helps to provide free and confidential counselling and support for young people.

We also heard some astonishing tales. Let me paraphrase just one of the stories of one of the people who came by, a woman who had felt suicidal for a year and had no fixed address. She went to see a GP, who asked her to come back regularly to check that she was okay. She went for a bit, only to stop going, but that triggered no alarm bells, even though a suicidal patient who was being monitored had stopped showing up. Eventually, she went to another GP and was told that she would be referred to a community mental health team, but nothing happened. Some time later, a third GP also suggested referral, but found nothing in her notes to suggest that she ever had been referred before. Three months after seeing the first GP, she was finally given an appointment to see a psychiatrist, but it was in five months’ time. The appointment happened and she was put on an 18-month waiting list for therapy. She is still on that list. In the meantime, she has lost her job and is in an extremely difficult situation. No wonder she and many others say that we need change.

Such a situation is not new. Eight years ago, my predecessor David Howarth spoke out against £3 million of cuts to mental health services in Cambridgeshire that led to the suicide of Julie Deloughery. There are many such stories across the country and across the decades. I heard some more when I worked with service users at Lifeworks, a mental health drop-in centre in Cambridge. The centre was threatened with closure, which I am delighted has now been stopped. I am proud that I was able to help with that by talking to service users and the mental health trust, and by raising the issue in Parliament, but I am far prouder of the work done by service users themselves and their friends. In particular, I pay tribute to Ann Robinson for her efforts. Too often, things are done to people with mental health issues, rather than done with them.

The now reversed decision on Lifeworks was partly the result of funding problems, so let me focus on the funding situation in Cambridgeshire, which has one of the most troubled health economies in the country. We are very underfunded. In 2013-14, our clinical commissioning group received the second lowest funding per head in the entire country. It has improved slightly since, but we are still far below where we should be. Somewhere has to be second lowest, but that is not a fair share. The Government have a fair share formula, but since it has been revised, rightly, to take account of deprivation, we have been left £35 million below the fair funding calculation. We get £961 per head in the Cambridgeshire and Peterborough CCG, whereas the figure for next-door West Norfolk is £1,255 per head. We are getting a slightly larger increase than others, at 2.9% rather than 2.14%, but at that rate it will take about a decade to catch up, with no compensation for the years of underfunding. I accept that NHS England makes decisions on how we get to the fair rate, but I hope the Minister will agree that the pace of change is simply too slow.

We have other problems. Our population is growing quickly: Cambridgeshire’s population growth is the fastest in the country and Peterborough is the fastest growing city. That means an even greater strain on funds, because the population increase is not properly taken account of. Our funding per head is going up slower than the national average, in spite of being low to start with. Will the Minister ensure that growth is no longer penalised? We also have a legacy of poor decisions, such as the two massive private finance initiative projects under the previous Government at Hinchingbrooke and Peterborough hospitals, the biggest and perhaps worst PFI projects in the country. They are still sucking money out of the system. When preparing for the debate, I was shocked to find that the PFI repayments for Peterborough represent a staggering 18% of the hospital’s budget.

We have less money than elsewhere, and we have more of that taken away from us before we even start, but we also have other legacy issues. Cambridgeshire is repeatedly used as a test bed for experimentation, such as the £1 billion privatisation of Hinchingbrooke hospital, led by and legislated for by the previous Government. They put the hospital out to tender and had not a single NHS bid among the final five bidders—Addenbrooke’s hospital pulled out because the cost was too large—so a list of three private bidders was left to the Government to choose from, which is not exactly a great choice to have to make. That is why I find it frustrating when the shadow Health Secretary claims to have clean hands over what happened with Hinchingbrooke. He claimed that one of the three bidders was an NHS provider, as he did in the House today, and I have been trying to find out which of the three—Circle, Ramsay or Serco—he considers to be part of the NHS. He said on Twitter today that it was the one associated with an NHS mental health body, but the day Serco counts as an NHS bidder is one I hope we will never see. Problems remain at Hinchingbrooke.

I am pleased, by the way, about the recent tendering for Cambridgeshire older people services, which I will talk about later. However, under the current Government’s legislation—which, incidentally, I opposed, because doing things in that way was not right for this Government or the previous one—the bid went to the NHS, with the mental health trust and Addenbrooke’s hospital providing the better services.

Cambridgeshire starts off with a particular historical situation and no money, so it is no wonder that we struggle to fund mental health properly. Things get worse. The CCG ran a small deficit last year, which is hardly surprising, but that makes it ineligible for quality premium payments, which could have brought in another £1 million. How can it make sense to starve CCGs of funding as a punishment for not having enough money to do the job properly? No one will be surprised to find that there is a correlation between budget outcomes and how well funded CCGs are: areas with funding above their fair-share calculations run surpluses, while those funded below their fair share run deficits and get punished for it. The deficit of £4.9 million from last year has to be repaid this year, putting even greater strain on the CCG, given an underfunding level of almost 10 times that figure.

In fairness to the CCG, it provides proportionately about the same allocation to mental health as everywhere else. We start off with far too little, however, so mental health gets far too little—one of the worst levels of funding in the whole country. That is in spite of long-term underinvestment and the huge pressures of growing demand—a 12% increase in the number of people with serious and enduring mental illness, but no extra money to cope with it. Given that the previous Government introduced a payment by results tariff system for physical health, but left mental health using the block grant system, extra demand—extra work—does not lead to extra funding. Yet again, changes were made to help physical health care rather than mental health care. As we rightly reduce stigma and tackle the huge unmet need for mental health support, more and more people will realise they need help and will seek it, but will discover that it is not there for them.

We have seen other problems. There was a suggestion from NHS England that there should be differential deflators—larger savings on mental health treatments than on physical health treatments. I know that infuriated my right hon. Friend the Member for North Norfolk, and I understand that the situation will not be repeated, which is welcome. I was disappointed to see that my own CCG complied with the suggestion, although in fairness it gave an extra £1.5 million for mental health services and as of next April will give a further £2.2 million to help meet targets for improving access to the psychological therapies programme.

The Nobel laureate Ernest Rutherford said, “We haven’t got any money, so we’ll have to think”, and providers in Cambridgeshire and Peterborough have had to be creative to cope with the awful funding position. We have seen many innovations. The mental health trust has set up a single point of access known as ARC—the advice and referral centre—reduced out-of-area placements and focused more on community teams. Its recovery college is doing good work in advancing the recovery model of mental health care.

We are doing some amazing things to use resources more efficiently in joint working. The £800 million contract for Cambridgeshire older people’s services—as I said, that stayed in the NHS—will combine acute trusts, mental health and community care, to help people seamlessly so they are not passed between one organisation and another. In particular, it should mean a sharp decline in the number of delayed transfers of care, where an older person is stuck in an acute hospital bed—at great expense and not to their benefit—because there is no alternative available in the system. No longer will Addenbrooke’s hospital have to negotiate desperately for community care beds; there will be one system. The contract design, with outcomes-based contracting, means that, rather than rewarding activity, there is an incentive to reduce the need for treatment. Keeping someone healthy longer is better for them and cheaper for us than treating them when they are ill.

We have to do much more on prevention, an issue I know the Minister cares greatly about. In his Five Year Forward View, Simon Stevens called for a radical emphasis on public health and prevention; promoting public mental health must surely be a key part of that, with resilience and well-being as the core. Mind recently called for local authorities to prepare public mental health strategies. Cambridgeshire county council’s health committee, chaired by the excellent Councillor Killian Bourke, has already commissioned such a strategy and plans to spend £120,000 on it. It will attempt not only to promote mental health in the very widest sense but to target groups that are particularly susceptible to experiencing problems, investing in effective, evidence-based interventions.

We also need to focus on recovery, on which the mental health trust’s recovery college is leading the way. Recovery is an approach to mental health that recognises that full recovery is not always possible—some conditions are lifelong—and seeks to enable patients to recover their lives from their conditions so they can live more fulfilled lives. That is in contrast to the attachment model, in which people are stuck as service users for ever. However, a recovery-led approach has to be properly resourced and must not simply be used as an excuse to close down services; otherwise, discharged patients will just be shut out of services and will return to being bounced around the system, looking for crisis care.

We need good crisis care as well, so that people can receive help. I again pay tribute to my right hon. Friend the Member for North Norfolk for his work on the crisis care concordat, bringing organisations together to deal with such crises. Currently, a huge load is placed on the police and acute hospitals—they end up dealing with people who should not be there but have nowhere else to go.

We must also make sure that there is a wider understanding of mental health throughout the health system. Primary care is key. I am astonished that GPs do not have compulsory training in mental health care. They will surely deal with mental health issues regularly, given that one in four of us will have a serious mental health condition at some point. Why are GPs not expert in mental health care? They could do far more to help people recover, remain independent and live better lives.

The voluntary sector is also key. I pay particular tribute to organisations such as Mind in Cambridgeshire, led by its very able chief executive Sarah Hughes; she has driven forward the crisis care concordat which was signed for Cambridgeshire and Peterborough just a couple of weeks ago. I also pay tribute to organisations such as Rethink Mental Illness, the Richmond Fellowship, Lifecraft, Centre 33, pinpoint, the SUN network, Arts and Minds and many more, whose work is hugely valued.

Finally, I will focus on an issue particularly close to my heart: child and adolescent mental health. It is a very important issue, because those who experience their first mental health problems at that stage can often be helped to recover completely. Often, the problems are a product of their environment, so early intervention can be radically preventive; however, waiting lists are far too long. In Cambridgeshire the health committee is trying to work with Centre 33 to provide more counselling support for young people. We have to go further on that and sort this issue out. Pinpoint and Healthwatch have recently contacted me about the urgent need to do more for child and adolescent mental health services. Many of my constituents have been in touch on that matter, as well.

There is far more that I could talk about. For example, I could discuss the troubled implementation of the Epic e-hospital system at Addenbrooke’s and the lessons we have to learn from that, the ongoing problems in the East of England ambulance service, or the desperate need to reopen community care beds in Brookfields hospital so that people can be moved from Addenbrooke’s into appropriate care. I could also talk about many positive things, such as the move of Papworth hospital to the Cambridge biomedical campus, which is proceeding apace, planning permission having recently been granted after my right hon. Friend the Chief Secretary to the Treasury approved the funding.

I will conclude instead with a plea. Mental health services in Cambridgeshire, and indeed across the country, are simply not good enough. I welcome the Government’s commitment to change that, and the idea of parity of esteem in particular, but it is not enough. We also need more money in mental health care across the board—hence my plea to the Minister for an extra £500 million targeted on mental health care.

In Cambridgeshire, we face a financial crisis across all forms of health care. Our low funding levels, historical commitments and growing population create a triple whammy. However, there is a way forward. Just yesterday, I took the chief executive of the mental health trust and the chair of the clinical commissioning group to see my right hon. Friend the Member for North Norfolk to make the case, and I think he was sympathetic to our position.

I will say here, to this Minister, what I said then to that one. There is an opportunity now, given the extra money that I and others campaigned for in the autumn statement. That extra £2 billion will have to be allocated somehow, so what formula should be used? I urge her in the strongest terms not to use the current ratios. That would mean giving extra money to areas already getting more than their calculated fair share, and less to those of us who are behind that fair share. Instead—I hope she will press NHS England on this—the money should be used to jump-start the shift to the new fair formula.

I understand why the transition is being made slowly—those areas with more funding than the fair share probably do not feel overfunded, even though they are able to run a surplus. But the new money allows us to correct the deficiencies for low-funded areas without creating losers. I am aware that £200 million has been earmarked for challenged health economies, and we are one of the 11 that have been so labelled. Although I welcome that, the Government should allocate all the money to move people up to the fair share if they are below it. I know that if our clinical commissioning group got the missing money—the £35 million that the fair shares formula says we should have, plus our share of the extra £2 billion—a high proportion of it could and would go on mental health care, transforming, helping and saving many lives. I hope the Minister will do what she can to make sure that that happens.

16:17

[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

It is a pleasure to serve under your chairmanship, Dr McCrea. I congratulate my hon. Friend the Member for Cambridge (Dr Huppert) on securing this debate and commend him on his ongoing interest in local health matters. I know from meeting the chair of his CCG only yesterday that my hon. Friend is a consistent champion of local services.

I am sorry that the Minister of State, Department of Health, my right hon. Friend the Member for North Norfolk (Norman Lamb), cannot be here to respond to the debate, but he has already shown a keen interest in its subject, and I know that he will take action forward. I also echo the tributes that my hon. Friend the Member for Cambridge quite rightly made to NHS staff at the beginning of his remarks.

We all agree that good-quality patient care has to be expected regardless of where in the country we live. As my hon. Friend quite rightly said, for too long, mental health services were the forgotten area of the health service. That is changing under this Government, and I will touch on that later. There is still, however, much to do; I am sure that we would all acknowledge that.

Although I will not dwell on the subject too much in this debate, my hon. Friend was right to comment on prevention and on building resilience. As the public health Minister, those issues are close to my heart. He was also right to talk in broader terms about building resilience in individuals. I know considerable thought is being given to making it possible for people—young people, in particular—to withstand more of what life throws at them.

I move on to questions of national funding. For 2014-15, NHS England allocated £64 billion to CCGs for hospital, community and mental health services—an increase on the previous year of 2.54%, or £1.59 billion. In making allocations, NHS England relies on advice from one of our many health acronyms, ACRA—the Advisory Committee on Resource Allocation. ACRA gives advice on the share of available resources provided to each clinical commissioning group to support equal access for equal need. Much of our debate will revolve around those funding formulas and how they are evolving. The calculation is based on the age of populations, their relative morbidity and unavoidable variations in cost. The objective is to ensure a consistent supply of health services across the country. The greater the health need, the more money is received, because more health services are needed. The CCG model covers only non-specialised hospitals and community care, plus primary care prescribing.

I understand that the baseline varies systematically between locations. To some extent, that reflects different historical commissioning priorities in the predecessor organisations—the primary care trusts—or different mixes between the local and area commissioning responsibilities.

NHS England reviewed the funding formula for 2014-15 and the following years, and it now uses the person-based resource allocation approach, which was developed by the Nuffield Trust. Unlike the previous target models, it allows information about individuals—including their age, gender and recent hospital diagnostic history—to be combined with information about the area in which they live; that information, as my hon. Friend knows, is frequently linked to deprivation. The PBRA formula estimates the relative need of each individual. At a CCG level, the estimates are the most accurate ever used for allocations, so there has obviously been a change in how resources are allocated.

In debates such as this we often discuss the pace of the change from the actual allocation towards the target allocation. The option that NHS England agreed for CCGs reflected the challenge of directing additional funding to the CCGs that are the most under target, while not destabilising areas whose allocations were above target—I have seen that happen in London. If people have had an allocation for a long time, we must ensure that they plan for the change; such things must be done sensibly. That is a continuation of the policy of maximising growth for those furthest below target. We appreciate that CCGs in the east of England are further below their target allocations than those in many other parts of the country—my hon. Friend is right to draw attention to that—and that Cambridgeshire is one of the furthest behind target by some £45 million or 4.85%.

NHS England is already spending £500 million in 2014-15 and 2015-16 to bring under-target CCGs, such as Cambridgeshire, towards their target allocations. That approach was discussed and decided at a public board meeting in December 2013—nearly a year ago. My hon. Friend is pushing us to speak about what will happen in the future. Following my right hon. Friend the Chancellor of the Exchequer’s announcement in the autumn statement of a further £2 billion for front-line services, NHS England is reviewing the 2015-16 allocations. I hope that NHS England shares the hopes of my hon. Friend the Member for Cambridge, and that it will consider how some of that extra £2 billion can be used to help the CCGs that are furthest behind—including Cambridgeshire—to get closer to their fair share. My hon. Friend has already discussed that issue with my ministerial colleague, my right hon. Friend the Member for North Norfolk, who takes it extremely seriously and is committed to raising the matter with NHS England before it makes a decision at its board meeting on 17 December.

Like my hon. Friend the Member for Cambridge, I recognise the commitment and dedication of the staff who provide mental health service, including those who work in specialist trusts and settings, and those who work in primary care and provide services daily. I was pleased that my hon. Friend spoke about the large army of people who are absolutely critical in mental health. They are often not formally part of the NHS composition of services, but their support is invaluable to it. They are the carers and volunteers, who sometimes work in charities or voluntary organisations—my hon. Friend referred to Centre 33 and a number of other organisations in Cambridgeshire. Sometimes they are simply individuals who help or care for a parent, a friend or a neighbour because they think it is the right thing to do. Without those people, the job of the health services would be immeasurably more difficult. Like my hon. Friend, I pay tribute to them.

[Robert Halfon (Harlow) (Con)]

On that point, will my hon. Friend the Minister praise West Essex Mind, whose annual general meeting is this Friday? It does so much to help mental health services in Harlow and across Essex, and it is an example of a charity that is deeply rooted in our community.

[Jane Ellison]

Of course I join my hon. Friend in paying tribute to that organisation. It is obvious from the comments of many hon. Members in this House that local branches of Mind and other groups do terrific work. My hon. Friend clearly has a good relationship with his local branch, and I thank him for placing his regard for it on the record.

The Government have increased funding for mental health by £120 million in 2014-15. Total mental health spending in England will rise from £8.5 billion in 2013-14 to £8.62 billion in 2014-15. The Department of Health and NHS England continue to work together on that important issue. I recognise the challenge faced by the Cambridgeshire and Peterborough health economy. I agree with my hon. Friend the Member for Cambridge about the private finance initiative decisions that the previous Government made about Peterborough, and about the legacy of problems that they left.

As my hon. Friend knows, action is being taken. NHS England, the NHS Trust Development Authority and Monitor are working on a programme to support 11 of the most challenged health economies, of which my hon. Friend’s is one, and to address those with long-term integrated plans. In Cambridgeshire, a programme jointly funded by all local NHS partners and underpinned by a concordat on joint working has been put in place. Its purpose is to find a collectively agreed solution to closing the financial gap facing the economy as a whole, while improving quality of care for my hon. Friend’s constituents and everybody else who is served by the local health economy. That work is due to identify proposals by the end of June 2015.

Mental health is an important part of that work, and emerging ideas focus around closer integration of physical and mental health, and an expanded role for mental health input in a range of hospital settings and community pathways, such as those for long-term conditions. As the Minister with responsibility for public health, I know only too well that people often have extreme co-morbidities, so we must look at them in the round and at all the things that interact with and affect their personal health care.

I know that there are concerns that mental health services could be disproportionately affected, which would not be acceptable. Although payment for mental health services is agreed locally, we expect local commissioners and providers to have regard for the national tariff arrangements. However, they can be flexible when there is good reason to be so.

The tariff arrangements for 2015-16 give a clear signal to the mental health sector to move away from simple block contracts, which currently apply in Cambridgeshire and are not transparent, to local payment models that support recovery and outcomes, as my hon. Friend highlighted, and that reflect the needs of local communities.

My hon. Friend is right that Cambridgeshire and Peterborough CCG invested an additional £1.5 million to address capacity pressures. His CCG is clearly committed to that, and he will continue to champion it. It has also committed to investing a further £2.2 million from next April to deliver the Improving Access to Psychological Therapies programme.

My hon. Friend is right to pay tribute to my ministerial colleague, my right hon. Friend the Member for North Norfolk, who has championed mental health policy in this Parliament very effectively. My hon. Friend the Member for Cambridge drew attention to the Government’s commitment to parity of esteem, which has been made explicit in legislation. Some 2.4 million people have entered treatment under the IAPT programme, and more than 1.4 million have completed that treatment. We invested £54 million in the period from 2011 to 2015-16 in the children and young people’s IAPT programme. My hon. Friend is right that child and adolescent mental health services are a critical part of our local care pathways.

For the first time ever, we have a mental health crisis care concordat to improve the system, signed by more than 20 national organisations. As my hon. Friend said, Cambridgeshire has already put it in place. We invested £25 million to ensure that vulnerable offenders are identified when they first enter the criminal justice system. The aim is to achieve 100% coverage by 2017.

There is a lot going on. We all acknowledge that there is a long way to go on mental health, but we have passed several important milestones on the journey. The NHS—both nationally and in Cambridgeshire—is working hard on the wider funding issues, and I hope I have assured my hon. Friend that progress is being made. He has already had a commitment from my right hon. Friend the Member for North Norfolk, but when I return to the Department I will reiterate that we want to make representations about the points he made to NHS England ahead of the critical funding meeting. I encourage my hon. Friend to keep closely in touch with his local NHS, although I can see that he does that. I thank him for securing this debate. I hope I have given him a measure of comfort and reassured him that considerable progress is under way on this important agenda.