Baroness Tyler of Enfield
That this House takes note of mental health care provision.
Baroness Tyler of Enfield (LD)
My Lords, I am delighted to have secured this debate, and with it such an array of knowledgeable and, I know, passionate speakers. I am particularly looking forward to hearing the maiden speech of my noble friend Lord Suri. For too long, the subject of mental health has been ignored, marginalised or left to the realm of social experiment or institutional stigma. Why does this matter? Just as we all have physical health, we all have mental health. Mental health problems affect one in four people in any given year, and the numbers continue to rise. In 2013, referrals to community mental health teams were up by 13%, and up by 16% for crisis services. As a consequence, services are often unable to cope, and people are not getting the support they need.
While 75% of people with a physical health condition get treatment, just 65% of people with psychotic disorders, and a mere 25% of those with depression and anxiety, successfully access treatment. John Lucas, a campaigner for the mental health charity Mind, has been diagnosed with both mental and physical health conditions, and speaks compellingly about the discrepancy between the care people receive for mental and physical health problems. He asks:
“Why does the NHS pull out all stops to stop me dying of physical health problems but does not care if I die of mental health problems?”.
Importantly, mental health problems are estimated to cost the country £105 billion a year through lost working days, benefits, lost tax receipts and the cost of treatment. So there is also a very strong economic case for investing in well-being, resilience and mental health. It is therefore highly appropriate that this debate takes place at a time when, although a lot of progress has been made, there is still much more to be done. We need to ensure that mental health services are equipped to respond to people with all sorts of mental health needs, ranging from preventive work and early intervention through to crisis care. We need to make sure that people who need mental health services, like those who use physical health services, can access care quickly, and have choices about what kind of care they receive.
This Parliament has seen real progress in mental health at national policy level. We have made real strides in awareness and public attitudes towards mental health. I pay tribute to my right honourable friends Paul Burstow and Norman Lamb for all that they have done in this area. Specifically, the cross-government strategy No Health Without Mental Health marked a breakthrough moment for mental health, and led the way for the commitment to parity of esteem between physical and mental health which is now enshrined in legislation and in the Government’s mandate to the NHS.
What has happened as a result? Last year, building on the £400 million investment in talking therapies, the introduction of the first ever access and waiting time standards for talking therapies and early intervention in psychosis, backed up by additional cash, was a welcome and long overdue step towards achieving parity of access to treatment for people with mental health problems. The mental health crisis care concordat should ensure that no one is left without support in a mental health crisis.
All localities have made declarations about working together across agencies to improve crisis care, and progress is already happening on the ground. For example, in Birmingham there has been a marked reduction in the use of police custody as a place of safety. I am sure we can all agree that a police cell can never be an appropriate environment for someone in a mental health crisis.
Of course, good mental health care is not just about treatment, but about empowering people to lead better lives. Recognising this, we now have more peer support workers in mental health trusts, and some 30 recovery colleges in place, to help people with mental health problems develop and achieve their own goals for recovery.
We have seen a real sea-change in the way people think about mental health. The MPs who participated in that famous debate in the House of Commons, and spoke so openly and movingly of their own mental health experiences, deserve much praise. Noble Lords in this House have also been open about their experiences. The courage of those in such positions in being open about their own mental health problems has undoubtedly raised the profile of mental health in Parliament—and, I hope, made it easier for others to speak out. Meanwhile, the Time to Change programme, England’s biggest anti-stigma programme, run jointly by the charities Mind and Rethink Mental Illness, is making a real impact both on public understanding and, perhaps more importantly, on people’s experiences of discrimination.
However, I am a realist, and despite this commendable progress, there is still a long way to go to achieve genuine parity for mental health in the NHS, and an equal chance in life for people with mental health problems. After generations of missed opportunities, I guess this is inevitable. So what are the remaining barriers that need addressing? To put it bluntly, funding for mental health services has faced disproportionate cuts compared with other services. Mental health services have always been known as a Cinderella service because of their chronic underfunding, and mental health receives only 13% of NHS health expenditure, despite making up 23% of what is called the burden of disease. Austerity has hit mental health services particularly hard. Mental health has seen real-terms cuts three years in a row. At the same time, demand is rising. By 2030 there will be approximately 2 million more adults with mental health problems in the UK than there are today.
Early intervention services are often the first target for cuts, but surely this is a false economy, because people’s problems then get worse, and they need more intensive and costly support. With their new public health responsibilities, local authorities have a real opportunity to prevent mental health problems developing in their communities. It is encouraging that some 35 authorities now have a mental health champion. However, research suggests that on average, councils are spending only 1.5% of their ring-fenced public health budget on mental health.
Even when people receive care, it is not always helpful. When we are unwell we are often told to see our GP in the first instance, and 90% of people with mental health problems are treated in primary care. But GPs themselves admit they do not always have the training they need to support people with mental health problems. I think all primary care services urgently need GPs and practice nurses with the confidence and expertise to improve people’s experience of primary care.
Evidence shows that a choice of care improves treatment outcomes, but people often do not receive the type of care they want. Talking therapy is the preferred choice of a majority of people with mental health problems, but only one in seven receive it. That is why I would like to see the right for patients to choose the type of treatment they receive enshrined in the NHS constitution—and for those who would rather have talking therapies than medication, there should be a choice of evidence-based therapies available, backed up by high-quality information.
I suspect that we can all agree that children and young people’s mental health services are a matter of real concern. Some 10% of children aged five to 15 have a mental health problem, yet funding for CAMHS has fallen by over 6% in real terms since 2010, and the commissioning of these services is far too fragmented, resulting in too many children and young people falling through the cracks. Too often they are taken hundreds of miles away from their home for treatment, or are admitted to adult wards. The Government are committed to fund more children’s beds, which is welcome, and have invested £150 million to improve support for eating disorders. We eagerly await the report of the Children and Young People’s Mental Health and Wellbeing Taskforce—a very long title. Can the Minister say when that is likely to be published?
Of course, children’s mental health begins at birth. It is critical to children’s mental health and resilience that they develop a secure relationship with their primary care giver—but are we doing enough to support new mothers who develop mental health problems during their pregnancy? More than one in 10 women will experience mental health difficulties during and after pregnancy, which often go unrecognised and untreated. According to the National Childbirth Trust, only 3% of CCGs report having a perinatal mental health strategy. I suggest that we could improve mothers’ access to mental health support by committing to including measurable objectives in the NHS mandate.
What else could and should be done? Schools have a golden opportunity to protect and promote children’s mental health and emotional well-being, at the same time as helping them achieve good educational outcomes. I would like the next Government to commit to raising awareness of mental health and well-being among young people by ensuring that mental health and emotional well-being form part of an enhanced and mandatory part of the curriculum for all schools, irrespective of their status. Yes, PSHE will be central to this, but such an approach needs to be embedded in the mainstream of the curriculum and the whole ethos of the school. As counselling can be an effective early intervention for young people experiencing mental health problems, and improve students’ attendance, attainment and behaviour, I would like to see all children in England having access to counselling, as children in Wales and Northern Ireland do.
People with mental health problems also face difficulties finding and keeping employment—2.3 million people with a mental health condition are out of work. Almost half of those receiving employment and support allowance are claiming primarily because of mental health problems, yet research shows that the vast majority want to work. It is clear that back-to-work schemes have little understanding of people with mental health problems and often assume that they lack motivation and willingness to work. What we need is personalised and specialist support to help them back into work, designed around the specific needs of people with mental health problems.
Finally, parity of esteem needs to be genuinely inclusive and work for all, including those who find themselves excluded or marginalised from society—those who are isolated or that third of people living with a long-term physical condition who also have a mental health problem. Certain black and minority ethnic groups and people with multiple and complex needs are often overlooked. People with a dual diagnosis—for example, those who have been diagnosed with a drug and alcohol problem as well as with another mental illness—are often denied access to mental health care on the ground that their substance abuse makes treatment impossible. When they are in crisis, they are more likely to be taken to a police cell than a health setting. It should not have to be that way.
Charities working together as part of the Make Every Adult Matter coalition, which I chair, have shown that by effective joint working, better care can be achieved for people with complex needs. I am pleased that the Department of Health is currently reviewing the 2002 guidance on dual diagnosis and hope that the continued rollout of liaison and diversion schemes will also start to address the issue of drug and alcohol abuse.
The next Parliament should set out an ambitious agenda for mental health. What should it be? Here is my starter for 10: mental health is not just a health issue. Therefore, we need a truly cross-governmental mental health and well-being strategy embracing issues such as employment, welfare, policing and criminal justice, housing, education and planning, as well as seeing Public Health England lead with the establishment of a national well-being programme championing preventive action. To lead this charge I would like to see a dedicated Minister for mental health with a cross-government remit and, indeed, the Secretary of State for Health reporting annually to Parliament on progress towards achieving parity of esteem between mental and physical health.
Next, we should rewrite the current system which discriminates against mental health and leads to institutional bias, including: making the NHS constitution fairer; introducing a wider range of access and waiting-time standards, along with entitlement to NICE-approved treatments for mental health problems; revising payment systems to put mental and physical health on an equal footing; and better aligned NHS public health and social care outcomes frameworks which put much greater emphasis on mental health. Finally, and perhaps most importantly, we should rebalance the NHS budget to ensure that mental health services for children and adults receive their fair share of funding and that metal health services see real-terms increases in investment in each year of the next Parliament.
To conclude, much progress has been made in mental health over this Parliament. The next Government—of whatever complexion or, indeed, combination—have a real opportunity to build on this momentum and transform the way in which we approach mental health in this country. It will take strong and courageous leadership both politically and from within the NHS, but the prize in terms of the nation’s well-being could be immense. I very much look forward to hearing what other noble Lords have to say on the matter. I beg to move.
Lord Goodlad (Con)
My Lords, I congratulate my noble friend Lady Tyler on securing this debate and on her very wise words.
I speak from the perspective of one whose home for the first 14 years of my life was a mental illness hospital: the Lawn in Lincoln—founded by the Willis family in 1819, following the successful treatment of King George III—of which my late father was for many years the medical superintendent. People have said to me, “What an unusual upbringing that must have been”—to which my only reply is, in the spirit of Elvis Presley, “She’s a distant cousin but she ain’t too distant with me”. An unusual upbringing it may have been, but it was not unusual for me. As I look back on those years, the memories of friendships with patients and staff remain with me as if it was yesterday. I see that part of my life through rose-coloured spectacles. My father wanted me to follow in his footsteps, as for some years did I. When that was not to be, grudgingly he said that my upbringing had been as good a preparation as any for life in the other place.
To be serious, much has changed since those days, most of it for the better. Public attitudes toward mental health have changed enormously, led I like to think by government and parliamentary action, and certainly reflected in Westminster today. There is a limited amount that the Government can do to influence public attitudes, and there is regrettably a very long way to go. In many ways, although progress has been made over the past 50 years, the glass is at least half empty. One in four adults during their life is traumatised by anxiety, depression, OCD, schizophrenia, dementia or another mental health condition.
The report of the noble Lord, Lord Layard, published by the LSE, sets out some stark evidence. Mental illness is now nearly half of all ill health suffered by people under 65 and it is more disabling than most physical disease. Yet only a quarter of those involved are in any form of treatment. The report of the noble Lord, Lord Layard, also pointed out that 23% of all ill health in the UK—the largest single cause of disability—is mental ill health, yet only 11% of England’s annual secondary care health budget is spent on mental health services.
My noble friend set out some of the costs—£100 billion a year, including 70 million lost working days, additional welfare benefits, lost tax receipts and the cost of treating avoidable illness. No price can be put on the suffering of those involved. Most of the millions of people suffering from depression, and children with behaviour problems, received no treatment, despite NICE’s recommendations. I hope that the Minister will be able to indicate how she thinks local authorities and clinical commissioning groups will deal with mental health care commissioning plans in the future.
There is, of course, support for the glass half full view of the situation. Premature death of people with serious mental illness has declined, although it is still too high, particularly for schizophrenia sufferers—20 years. The quality of life of many mentally ill people has improved, as has the experience of healthcare. The Royal College of General Practitioners has committed to making improved care for people with mental health problems a training priority. I well remember as a child accompanying my father in his car as we followed the tail lights of general practitioners in rural Lincolnshire on domiciliary visits. Perhaps this will not have to happen so much in future, and reference to community health teams will be quicker.
I do not doubt the good intentions of the Government and I pay tribute to the recent work of Jeremy Hunt, Norman Lamb and Simon Stevens. The Government have legislated for the first time for parity of esteem between physical and mental health. The intention is that most patients needing a talking therapy will be guaranteed treatment within six weeks, with a maximum wait of 18 weeks, and that patients experiencing their first episodes of psychosis will receive treatment within two weeks. Let us hope that these aspirations result in action—fine words butter no parsnips.
The children and young people’s mental health and well-being task force has been established. The mental health crisis concordat has been signed by 20 national organisations. The Government have announced that everyone who receives mental health care should have a named, accountable clinician. Mental health has now been made part of the new national measure of well-being so that it is more likely to be taken into account when government departments are developing and implementing policy.
My late father was one of the pioneers of day care. I am not sure that, seeing the outcome of care in the community in some of our inner cities, despite the deep commitment of carers, social workers and health workers, he would be convinced that an adequate solution has been found. What is required is a holistic approach, co-ordinating social care, general practice, liaison psychiatric and mental health specialist organisations, housing and education authorities and prisons. What we need is not just talk in Whitehall but action.
The Health and Social Care Act for the first time in statute places a duty on the NHS to promote research. It is in the context of research that I turn to schizophrenia. I pay tribute to the work of charities such as Rethink, Mind and SANE—Schizophrenia, A National Emergency —founded and so ably run for many years by Marjorie Wallace, and of which I was a director for some time. There is now a schizophrenia audit, and depressing reading it will make.
The exact causes of schizophrenia psychoses are unknown. They are among the commonest and most serious mental health conditions. Only one in 10 people who are diagnosed with schizophrenia is in work. Stigma still attaches to the condition. The human cost is colossal, the financial cost in terms of resources used is enormous and the distress to sufferers and their families is inconceivable. Schizophrenia affects about one person in 100 at some point in their life. It is estimated that it costs the UK taxpayers about £2 billion a year in care and treatment, together with the vast personal cost, both financial and in terms of suffering, for patients and family members. The global drugs bill alone is estimated to be £12.5 billion a year, not including hospital stays.
So where are we now? Last year the Harvard Gazette published an article saying that there had been little innovation in drug development for the treatment of schizophrenia in more than 60 years. It went on to report on efforts to identify,
“more than 100 locations in the human genome associated with the risk of developing schizophrenia”.
The hope is that this might lead to the development of new drugs. Despite the pressing need for treatment, medications currently on the market treat only one of the symptoms of the disorder—psychosis—and do not address the debilitating cognitive symptoms. Treatment options are limited because the biological mechanisms underlying the illness have not been understood. The sole drug target for existing treatment was found serendipitously, and no medications with fundamentally new mechanisms of action have been developed since the 1950s.
Great work is going on in the United States, financed by foundations and philanthropic donations, and there is an international project on genomes. On this side of the Atlantic, mental health has always been a poor relation in the charitable sector, with the exceptions of Alzheimer’s and autism. Mental health charities will not, in the foreseeable future, be able to compete with physical health charities, such as those devoted to cancer. That puts the Government in the firing line. The Institute of Psychiatry at King’s College London has been given £5 million for a project, but nothing will come from that, I understand, for a decade. So there we are: little progress over 60 years.
I hope that the Minister will give me some comfort that the Government understand the urgency of further research into the causes of schizophrenia psychoses and the crucial role of the Government and the NHS in promoting it. Mental health has been described, with justification, as the Cinderella of the NHS—but let us remember with hope that Cinderella had a happy ending.
Lord Storey (LD)
My Lords, I am very grateful to my noble friend Lady Tyler for securing this debate. With three children in every classroom experiencing mental health problems, teachers need the right training and support to identify issues early and ensure that young people get the help that they need to recover and thrive. I would like to use my time to focus on mental health care and support in schools and on the creation of an ethos that does not ignore mental health problems but has the readily available resources and support to help children and young people proactively. Making such support available and accessible will not only be life changing for the pupil but head off later problems and lead to later savings in human and financial costs.
A recent survey by CentreForum, as part of its mental health commission, concluded that 54% of head teachers found,
“mental health services ineffective in supporting pupils”,
while, at the same time, mental health issues are on the rise in schools. Confidence in child and adolescent mental health services, or CAMHS, was even lower among head teachers at pupil referral units, at 37%, and at special educational needs schools, at 43%. Sixty-five per cent of schools do not assess the severity of mental health needs among their pupils, yet where such screening tools are available 85% of schools reported it to be effective.
As the Deputy Prime Minister rightly said,
“Schools would never ignore a child with a physical health problem, so the same should be true of mental ill health too”.
He went on to say:
“Early intervention is crucial in tackling mental health problems”.
So early identification and the provision of effective support systems are paramount in dealing with mental health problems. However, two-thirds of local authorities have cut their child and adolescent mental health services, and, unfortunately, the largest cuts have been to early intervention services.
We need to provide alternative solutions which benefit families and young people affected by mental health problems and which take into account the existing responsibilities of teachers. For example, the Well Centre in Streatham, south London, provides drop-in one-to-one counselling, structured therapy, peer group work and digital services. Since CAMHS budgets have been reduced, we must look to investing in alternatives, such as linking up schools with these youth health centres in order to reach out to young people who may not have the confidence to ask for themselves.
As a Government, we have been successful in introducing free childcare for increasing numbers of disadvantaged children, implementing education, health and care plans to enable quality and consistency for all young people with special educational needs and providing for further integration of crucial services that affect the well-being of children from birth throughout their education. However, mental health care for under-25s still makes up only 6% of the overall NHS mental health care budget. We must therefore continue to work towards preventing the suffering of those children with emotional, behavioural and psychological problems.
I believe this can be achieved by creating the conditions that allow for early diagnosis. It can also be achieved by addressing the factors that can contribute to the stigmas surrounding mental health and maintaining high standards of mental health services for every child and family. It is our responsibility to enable every child to receive the best possible start in life. The only way that we can safeguard this right is by ensuring that education and healthcare services are equipped to tackle the underlying causes and contributory factors of mental illness. In doing this, we can help pave the way for improved physical and mental health for our children and, further still, support opportunities for all young people to learn effectively.
We all believe that education and care for young people should provide the best start in life for every child, regardless of their background, their living circumstances or the socioeconomic status of their parents. Over the years, we have seen that early years and childhood experiences can have profound and long-lasting consequences for an individual’s health. We know that the life chances of a child are greatly influenced between the ages of three and five, and that their future chances are often predicated on their development in the first five years of life. If undiagnosed, mental health problems can continue to affect young people throughout their life, affecting their personal development, educational attainment and overall well-being.
During my time as a head teacher, it was often clear to see that children from disadvantaged backgrounds were arriving at school, on their very first day, already a few steps behind their more fortunate peers. This had severe implications for their learning capacity, their ability to interact with classmates and even their literacy and numeracy attainment levels. While we tend to presume that such disadvantage is primarily caused by social and material circumstances such as poverty, family structure and demographics, all too often we neglect the role that mental health plays in child well-being. Yet around one in 10 of the nation’s children are affected by mental health issues, with significantly higher levels evident in certain groups of young people.
Many education providers, parents and children alike find themselves confronted with the challenging realities that are presented by mental health care provision, and teachers are increasingly placed under considerable pressure to take responsibility for such demands. It is vital that education, youth services and healthcare providers have the capacity to work together in identifying mental health problems at the earliest possible point, in order to offer early diagnosis and professional, collaborative support.
Furthermore, early diagnosis and support for affected children and families can significantly reduce costs to society in the long term, as well as empowering those who are affected to help themselves. Targeted interventions and the provision of integrated services at an early age are key strategies that have been proven to help reduce low educational attainment, unemployment, crime, and anti-social behaviour in the long run. The benefits of interventions during the early years of childhood are therefore realised both in the short term and over the entire life course of the child. As such, we should see the provision of mental health care in the foundational years as a valuable investment.
We need to look specifically at the treatment of mental health for young people, and make sure that this treatment is accessible to high-risk groups. We need to ensure that there are flexible, sustainable and workable plans in place for young people affected by emotional illness from birth, and that care continues to be accessible throughout their lives.
Finally, we need to cut right to the core of the issue, and act on the advice of medical professionals who emphasise the influence of perinatal mental health on a child’s upbringing. If mental health problems are identified and treated quickly, efficiently and effectively, many of these serious long-term human and economic costs can ultimately be avoided.
I thank noble Lords here for their dedication in debating the importance of mental health care provision, and urge us all to consider further investment and accessibility in services for young people, as a crucial way in which we can prevent emotional disturbances from affecting the life chances of children from all walks of life. It is reassuring to see the progress that we have made in firmly placing mental health care provision on the agenda, and I look forward to seeing the Government, local authorities, trained professionals, and parents continuing to uphold the highest standard of care for young people.
As Dame Sue Bailey, chair of the Children and Young People’s Mental Health Coalition, said:
“School is a critical environment where young people should be able to flourish across all domains of their lives. The gaps and concerns this report so clearly identifies reinforce the need to provide young people with the help, support and self-empowerment to develop and maintain resilience to stay mentally healthy in order to achieve and develop to their full potential”.
I say, “Hear, hear”.
Lord Suri (Con) (Maiden Speech)
My Lords, I would like to thank all noble Lords on all sides of the House and the staff of this House for their immense kindness and friendliness in making me so welcome to this honourable establishment, navigating me through the protocols and giving me advice and guidance to enable me to fulfill my new role in this House. In particular, I would like to express my heartfelt gratitude and thanks to my supporters, my noble friends Lord Popat and Lord Leigh of Hurley, for introducing me to your Lordships’ House.
Little did I know back in 1974 when I emigrated from Kenya to the UK that I would be bestowed with this great honour to work alongside your Lordships to continue contributing towards building a cohesive multicultural society in this country. I am humbled to join this House and family, which strives to represent the diversity of the population in this great nation. I am the second turbaned Sikh who has been elevated to the upper House. This great British institution has taken a praiseworthy step by bringing into its fold people of different faiths.
I have spent all my working life as a businessman, with a career that started in Kenya as an importer of educational supplies. This was the start of my liaisons with the United Kingdom, dealing with long-established British publishers. In 1974, having decided to migrate with my family to the United Kingdom, I pursued my business ambitions and challenged myself to a new business venture. I decided to enter into the fashion accessories trade, and much to my disbelief I encountered a harsh reality not previously experienced. The estate agents who offered me business premises to rent strongly advised me not to be the front man in a fashion accessories boutique as customers would not be forthcoming. Instead, my wife was recruited and she ran our boutique full time while I ventured onwards looking for further trading opportunities.
We were determined to stand on our own feet and to earn our living without committing to the state for benefits. In 1977, I established a wholesale fashion jewelry and accessories business, and through its success I built up a sound property portfolio. The company is still trading strongly.
Through my selfless and entrepreneurial approach to business, I have always remained actively involved with many charities, social action projects and social initiatives. This is in keeping with my firm belief that people should contribute back to society to help others in less fortunate positions. Service to charitable and voluntary works has always been deeply rooted in my ethos on life. Service to mankind and praying for the welfare of all is one of the principal pillars of the Sikh religion.
I have been treading on this noble road to serve others from a very young age. Over the years I have championed community work and have held posts including justice of the peace, general commissioner of income tax, serving on the Middlesex Probation Committee and the Home Office Advisory Council on Race Relations, being a member of the board of visitors of HM Prison Pentonville and mentor to the Prince’s Trust youth business trust.
I thank my noble friend Lady Tyler of Enfield for putting down the Motion for today’s debate on the importance of mental health care provision. Good mental health, as well as good physical health, is essential in enabling us to contribute to the socioeconomics of society. The relevance of today’s debate endorses over five decades of my contributing to the community, voluntary services and charities, starting in Kenya and continued in Britain with unremitting devotion.
During my involvement as a voluntary associate at HM Prison Wormwood Scrubs, prior to commencing my voluntary career in probation and magistracy, it was evident that poor mental health and the lack of mental health care provision hindered people from making the journey to recovery. I would like to share with your Lordships a particular case where I supported a fellow Sikh who was imprisoned for having committed murder. This individual, who I will call Tej, which is not his real name, was further isolated in this environment through lack of communication, as he was not literate and unable to converse in English. Tej was fluent in his mother tongue Punjabi, which limited his interactions and intensified his isolation and sense of hopelessness, contributing to his depression and placing him at a high risk of suicide.
Through my weekly visits, we established a rapport. Over time, Tej was persuaded to join literacy classes in the prison, which reduced some of the isolation and frequency of suicidal thoughts. Through continual support, Tej was transferred to a prison nearer to his home town in order to rebuild his relationship with his family, who had severed all links with him.
My work within the prison environment led me to visiting the young people at Feltham young offender institution. These young men were institutionalised as a result of their criminal activities, with an outlook of further poor outcomes in the future, and once again the state of their mental health contributed to the sense of despair and low aspirations. It could be said that the young people were like tender green shoots waiting to be trained along a framework that would build on their aspirations. They would acquire new skills and knowledge through education, which would be utilised in a productive way to reduce the cost to society.
It has been important to me to have put my business skills into the field and mentored young people through the Prince’s Trust youth business trust, sharing my knowledge and experience of starting businesses, thereby giving them the tools to take the first steps in building a new life and contributing to their community but also to the economy of the country.
Education has a multidimensional impact on every member of society and should be for all to take on board as a lifelong journey of learning, discovery and character building. In 1956, I had the privilege of meeting the President of the Republic of India at that time, Mr Sarvepalli Radhakrishnan, who was visiting Kenya to open the Mahatma Gandhi academy. In his speech, he emphasized that, although he was an academic, philosopher and statesman, he still considered that the world was his school. This analogy has influenced my thinking on education, which has brought me here today. I am sure that the provision of mental health services will remain high on the agenda of this House.
Lord Patel (CB)
My Lords, it is a great pleasure on behalf of the whole House to congratulate the noble Lord, Lord Suri, on his maiden speech. As he mentioned, he is the second Sikh to enter the House of Lords. He has also represented 450,000 Sikhs through his honorary secretaryship of the Sikh forum. No doubt, he brings his experience and wisdom from that time of representing Sikhs who contribute so widely to this society. He evaluated the many contributions he has made to the wider society in faith and commerce. He has also been a magistrate for over a decade, so he has many talents. Today he has demonstrated his commitment to mental health and his experiences in supporting prisoners. We welcome him to the House and look forward to hearing from him on many occasions.
I am going to concentrate mainly on what parity of esteem means. I declare two interests. I am an honorary fellow of the Royal College of Psychiatrists, not because I have contributed much to mental health but for reasons I do not understand. The second is why I am interested in parity of esteem. Some noble Lords will remember that, during the debate on the Health and Social Care Bill 2012, I spoke on an amendment to give mental health parity of esteem. I was the third name on the amendment. The first name was that of the noble and learned Lord, Lord Mackay of Clashfern, and the second was that of the noble Baroness, Lady Hollins, one of the most respected psychiatrists in the land. Neither of them could attend that day and it was by chance that I called a vote which was won by four votes. Parity of esteem is now in the statute because of those four votes and the fact that the other place did not overturn it, presumably because of the wisdom of the coalition Government—I emphasise coalition.
Much has been said in the past two years about parity of esteem. It has almost become a slogan. Whenever anybody speaks about mental health, whether they work in the mental health field or in health services generally, they talk about parity of esteem. It means different things to different people, but it probably means nothing at all to the public, the patients and their families. Turning the slogan into the practicality of what it should be will make the families and patients feel what parity of esteem for mental health is.
The duty to ensure parity of esteem was enshrined in the Health and Social Care Act 2012, by securing improvement,
“in the physical and mental health of the people of England, and … the prevention, diagnosis and treatment of physical and mental illness”.
This duty provided a legal backing for the commitment to parity of esteem within the Government’s 2011 mental health strategy, No Health Without Mental Health. However, parity of esteem in mental health refers to a broad range of issues which reflect the role of mental health across all the different areas of our lives. “Parity” therefore refers not only to equivalent levels of funding for mental health but to a whole range of areas which affect our mental health—in and out of mental health services. Furthermore, parity of esteem needs to address “parity within parity”. By that, I mean the inequalities within mental health in terms both of the differential prevalence of mental ill health within marginalised groups and of achieving fair and equal access to services.
Parity of esteem and its applications may come in different forms. When we look at parity between physical and mental health, we see a persistent mortality gap between people with a diagnosis of bipolar disorder or schizophrenia and the general population, as has already been mentioned. Measuring the parity gap may focus on the excess mortality that patients with mental ill health suffer. They die 15 to 20 years earlier than those who do not have mental ill health. The parity measurement gap may also refer to the burden of disease. One-quarter of the NHS disease burden and disability is due to mental health.
The parity gap can also be measured by the treatment gap; that is, the number of people who may have a condition, but do not get the treatment for it. It is as low for common mental disorders as 24%, compared to 85% for a broken hip. The parity gap in treatment is therefore considerable.
In cases such as schizophrenia, the gap in the general population is widening among certain groups. Problems such as diagnostic overshadowing mean that the physical health needs of people with mental health problems are not sufficiently investigated. Only recently have waiting time targets been introduced for psychological therapies, already mentioned, in contrast to long-standing physical health waiting times. In mental health, we currently see one in 10 people waiting up to a year to receive treatment, particularly for psychological therapies. It is still hard to get the full range of NICE-recommended psychological therapies—only 15% of people are offered the full choice of approved therapies.
Mental health must also have an equal footing with physical health in public health strategies. There is clear evidence and a convincing economic case for investing in public mental health. Parity in funding has already been mentioned. Mental health has been historically underfunded compared to physical health. At present mental health accounts for only 13% of NHS spend on health, despite accounting for 23% of the burden of disease. Mental ill health is also the single largest cause of disability in the UK. Investment in mental health research is key to advancing parity of treatment for mental health.
Despite mental health problems affecting one in four of us, funding for mental health stands at less than 6% of all health research funding. A commitment to parity in funding must be consistent across government and health services. In 2014 Monitor announced a funding decision to cut mental health services by 20% more than NHS hospital trusts. I know that Ministers did not approve of that, or like it, but none the less, the funding was cut. Reports found that 77% of clinical commissioning groups have frozen or cut their children and adolescent mental health services budget between 2013-14 and 2014-15, alongside 60% of local authorities in England having cut or frozen their budgets since 2012.
Mental health services must see real-terms funding increases to be equipped to meet increasing demand and unmet needs for both adults and children. Parity within mental health is essential to ensure that anyone who experiences a mental health problem has fair and equal access to treatment, especially among marginalised groups. This includes adapting services to make sure that they are inclusive of all. There are no hard-to-reach people—there are only hard-to-reach services.
One way to address this is through the coproduction of services. Outcomes for people with complex needs and from minority-ethnic communities are unacceptably poor. This also means that mental health services should be appropriate for people across the life course, from children to later life. Young people need to be given the skills to address life’s challenges with the confidence to manage their well-being, and older people need services that are accessible and appropriate. Health inequality increases the likelihood of experiencing mental ill health, and addressing inequalities can promote the population’s mental health.
Parity and stigma is another issue, which some noble Lords have already mentioned. Nine out of 10 people with a mental health problem experience stigma and discrimination. It is essential that the work of the Time to Change programme continues to improve public and professional attitudes to mental health. It is essential to eradicate the stigma surrounding mental health in professional health settings, as stigma affects the esteem in which professionals are held.
I have two questions for the Minister. First, what steps are the Government taking to reduce the imbalance in the provision of publicly funded research into mental health? Secondly, what are the Government’s plans to ensure that mental health services are appropriate for people across the life course?
Lord Farmer (Con)
My Lords, once again the noble Baroness, Lady Tyler, has secured a debate of vital national importance, for which I thank her. I take this opportunity also to congratulate my noble friend Lord Suri on a very fine contribution to this debate. I am aware of the considerable expertise that lies within your Lordships’ House on the issue of mental health, so it is with some humility that I approach the subject—but also with a conviction that there are neglected issues, and it is at these that I will pitch my comments.
My overriding concern is with the drivers of our high levels of mental disease—I use that term deliberately. When a nation as great as ours has prevalence rates of one in six adults at any one time suffering profound mental distress, as well as one in 10 children and young people, this surely reveals an underlying and widespread societal dis-ease. Mental illness does not just happen: very often there are preventable causes, and this is where a new wave of public health effort needs to focus.
We have just heard from the noble Lord, Lord Patel, that mental health is the single largest cause of disability in the UK. It is responsible for a quarter of the disease burden and 13% of the NHS budget. Although that disparity will, I am sure, be the concern of others here today, I would ask us simply to pause for a moment and consider how much is already being spent, and how much human misery it represents, rather than simply asking for more money. Moreover, it is a fraction of the overall cost to society, estimated by the Centre for Mental Health at £105 billion every year. We simply cannot afford these eye-watering costs and loss of human potential, so I emphasise the importance not just of treating mental illness but of preventing it from occurring—or recurring.
It is now widely accepted that we need to adopt a bio-psychosocial model to understand the causes of poor mental health. To put it more simply, it is not just about genetic predisposition, it is also about the kinds of families and communities people grow up and live in, the character of schools and workplaces, and societal attitudes. If we are serious about preventing mental dis-ease, we have to step back and ask some fundamental and searching questions about the kind of society we want our children and grandchildren to be born into, grow up in and grow old in. First and foremost, it should be one where the unique human worth of every individual is appreciated and which places a very high premium on relationships. With this as a backdrop, I will now unpack what is meant by a bio-psychosocial model, highlight key issues in these three areas where we need to see profound cultural change and recommend how this might be achieved.
First, in terms of biological drivers, drug misuse can be both a cause and effect of mental illness. The British Journal of Psychiatry reports that 80% of first-episode psychiatric disorders, schizophrenia or schizophrenia-like illnesses occur in either heavy or dependent cannabis users. Individuals using cannabis are doubling their risk of developing schizophrenia. This undeniable risk to mental health is why I am so strongly opposed to legalising cannabis. We need to send a clear and unambiguous signal to our young people that drug use, which many of them think is somewhat cool, is strongly implicated in the development of mental health problems—which everyone would agree are deeply uncool.
Similarly, I consider it highly appropriate for the Government to fund information campaigns such as Time to Change, which the noble Lord, Lord Patel, just referred to, which address the stigma of mental ill health. This deters many people from coming forward for treatment when problems are at an earlier and possibly more manageable stage. Stigma has to be seen alongside the second area of social factors, which include isolation and loneliness, unsupportive and hostile communities, poor housing, inadequate healthcare, financial poverty and sexual or racial discrimination.
The risk of psychosis among Black African-Caribbean groups is seven times higher than among the general population. They are more than twice as likely to commit suicide and three times more likely to be admitted to hospital. They are more than 40% more likely to be sectioned—in other words, detained without their consent under mental health legislation.
Prevention of hospitalisation is a worthy goal for financial as well as therapeutic reasons. I will describe how voluntary sector organisations can do just that. Recent polling found that, of those with experience of hospitalisation, more than half did not feel the settings and facilities aided recovery; 44% felt that the treatment they received was fairly or very ineffective; and 14% felt very unsafe. People who feel unsafe in hospitals are not necessarily simply nervous types. I have heard how returning soldiers with post-traumatic stress disorder consider UK hospital settings more dangerous than the Iraq or Afghanistan front line. It should not be possible to spend one’s days in a mental health ward, hunched up on the floor against the wall, alone with one’s troubling thoughts, while nurses busy themselves with bureaucratic tasks. One study found that only 16% of patients’ time was passed in what is loosely termed “therapeutic interaction”. The remaining 84% was characterised by a distinct lack of purpose.
I understand how much pressure mental health professionals are under. The Mental Health Act Commission found that nurses were unhappy about being too busy to develop therapeutic rapport with patients. The commission concluded that all hospital wards caring for detained patients should ensure that they have “protected engagement time” with nursing staff. I endorse that recommendation. Everyone needs to feel that they are significant, that they are worth spending time over and that they belong.
This leads me to a third category of psychological factors. These include insecure attachment to parents in infancy, sexual or physical abuse in childhood, inadequate, neglectful or abusive parenting and being bullied or harassed—in other words, continually feeling unsafe. This is possible even in the workplace, because of one’s own line manager. Bereavement, lack of any close confiding relationships and family breakdown are also factors. I keep promising myself that I shall give a speech in your Lordships’ House in which I do not mention family breakdown. It is getting very difficult to do that because of its myriad, knock-on effects.
There is a strong evidence base about the impact on a child of losing one parent, which sadly goes beyond the financial or emotional and reaches into the heart of this debate. According to Professor Richard Whitfield, for a child to surface, somebody needs to be crazy about them. Morgan and Fearon, researchers at the Institute of Psychiatry, found that family breakdown and early separation from a parent had a clear effect on rates of psychosis in the African-Caribbean population, where there is a higher likelihood of growing up without both birth parents. Insights such as these make it even more imperative that we address family instability, which affects poor communities of whatever ethnicity particularly badly.
Honesty requires us to admit that one’s birth family can be at the root of mental health problems. The first onset of mental health problems is commonly in childhood or adolescence. Half of all lifetime cases have started by the age of 14. A prevention agenda has to make parenting support a major priority. There is a great prize in helping families repair and its members become a resource to each other. Families can also be at the heart of the solution. Recent polling found that more than half the people with mental health difficulties received “a lot” of help and support from their families. This was more than those who cited their GPs and three times as many as those citing psychiatrists. We urgently need better family functioning to be included in the national Public Health Outcomes Framework. This would mean that local authorities had to ensure that couple support and family therapy were offered as standard—for example, in the family hubs for which I am pleased to hear there is growing cross-party support.
There must also be greater recognition of the role that supportive communities can play because not everyone lives in a family. The black-led churches are on the front line of preventing mental ill health. Organisations such as the African Caribbean Community Initiative in Wolverhampton are helping to keep many black people out of hospital by inspiring confidence in mental health professionals that their patients are safe in their hands.
That is what we all need for well-being and good mental health—reliable relationships, whether in families, the workplace, healthcare settings, faith communities or during our retirement years. The Government have a clear role to play by pursuing policies that will strengthen rather than undermine these relationships and the innate desire and ability that people have to look out for one another. I am my brother’s keeper.
Lord Addington (LD)
My Lords, the first and very pleasant duty that falls to me today is to welcome from these Benches—from this part of the coalition—the noble Lord, Lord Suri. A good start has been made and we look forward to what is to follow.
When I put my name down to speak in this debate, it was because of something which is blindingly obvious to somebody such as me who has dealt with disabilities for many years. Somebody who is disabled is likely to undergo slightly more stress than somebody who is not. Stress seems to be one of the key factors, whether it comes from family, or social background. With disability—that is, not being able to function—there is going to be more stress and there are probably going to be slightly more mental health problems there. It is a little bit of a no-brainer.
However, many of the speeches today have touched upon that. I always regard people as being a cocktail of a series of events, circumstances and chance and all these things come together in individual people, making them slightly more likely to go in certain directions or react in certain ways. If you are a person with a disability, who struggles to access certain parts of society or to communicate, or to achieve as your peers would, it is an almost dead cert that you will be slightly more vulnerable and there is a slightly higher probability that mental health problems will occur in your life. Virtually all the reading I have done backs this up, and everyone who has spoken to me has said so.
On the issue of dyslexia—the noble Lord, Lord Farmer, might have said that he always talks about family breakdown; I am trying to find a subject where I cannot find an aspect on dyslexia and my connection to it and I have failed so far—it is well known that dyslexics get slightly more stressed in the classroom and that mental health problems will be that little bit more common among them. However, they are not the only group. When it comes to autism, 70% of young autistics are reckoned to have a mental health problem. That 70% equates to 1% of the population. The on-costs of not dealing with this in the best way are massive. To deal with just those two groups at first, most of those have economic capacity and the capacity to work, but that will be greatly reduced by not giving them support and help throughout. By not taking action, we are effectively creating that little bit more of a burden or drag on society and making people’s lives more unpleasant.
All those whom I have spoken to in this field say that there is one problem that the medical world—and, indeed, the rest of the world—has in dealing with this. When they see a person who has a disability, whether obvious or hidden, they tend to see the disability first rather than think about what might be going on behind it. I remember that we had a long debate in this Chamber about how the deaf, or British Sign Language users, access the health service. How much more difficult is it for a doctor or a professional to establish that mental health provision is required when they cannot understand the person, who has to be translated through somebody else? There are sometimes difficulties there, so how do we address this?
If we are serious about taking this very sensible and good step forward of giving parity to those with mental and physical health problems, the first thing we must do is surely to ensure that all those in the health service are at least aware that this possibility is there. I am talking about everybody not becoming expert and trained but being aware that there might be a problem, which they should assess and move on from. A degree of awareness can be achieved fairly easily, simply by stating, “By the way, in certain groups certain types of conditions are more frequently occurring”. Once again, that is a no-brainer, but what is required to move you on?
Regarding the education sector, my noble friend Lord Storey mentioned how the Department for Education deals with mental health. In education, we have for a long time dealt with special educational needs, but most of the problem that we have is in identifying them and getting the system to recognise them. I do not say that the Department of Health is going to become any worse but without training, without pushing to make sure that it is kept under surveillance to do so, it will not be any better. That is because it will think—and it may be right—that it has enough to do as it is in dealing with the duties in front of it. That will be so unless you place a duty on that department to become aware or find out and make sure that, when it does not, it must report back the reason why. That is both to reinforce the fact that it is a duty and so that the systems are in place to make sure that it does not happen again. If we do not undertake this type of activity, we will reinforce this cycle of people who are underachieving.
We will not address the selfish interest of society properly unless we become aware of this. We will have a whole section of our society who we are encouraging by saying, “You should go out to work and become fully active”. Indeed, we are making that a legal duty; all Governments in the last few years have done this, saying, “You should get out and earn. We don’t want you sitting at home”. But unless we make sure that they are supported the whole way round they are going to fail in this, effectively because they have no option.
If we look at other areas where bad mental health is prevalent and disabilities, often hidden, are common, we could look at prisons. I thought that I might say a few things on that, but I looked at the speakers list, and then across the Chamber, and saw the noble Lord, Lord Ramsbotham. Whether or not he chooses to take a bite out of this particular apple today, I will always defer to him on that issue, but we should look to the examples of how we get such “co-morbidity”, which I think is the correct term here—personally, I think the word means that you are dying twice and quickly, so perhaps we should say “co-occurrence”. For an example of where co-occurrence leads to failure and expense, you need look no further than prisons. This is particularly true of conditions such as autism and other hidden disabilities. In all the cases at which I have looked, not looking at the whole person or beyond the initial aspect will lead you into trouble.
I am in grave danger of reciting all the facts that I have about the problems in these areas, such as that people with a learning disability were traditionally seen as not being worth indulging with a talking cure —because it would not do them any good because you cannot help them anyway. However, they can become more independent and they can get out there. Unless we address the idea that we give all groups in this sector as much help as we can, we will fail. In failing, we pass on costs to society and to those in families who end up looking after these people.
Carers have a high occurrence of mental health problems. They are under stress. We must start to cut this Gordian knot or break the circle—the clichés roll on—and address this by saying that you must look for this problem, think of a strategy and get into the system some awareness of those who are using it. We must also make sure that the medical profession is prepared to take advice on this subject from outside. Unless we do these things we will not ultimately get the full benefits of a very sensible strategy. We must exercise our peripheral vision and think laterally on this, because it will touch every aspect of society. If we do not, the strategy will not work.
Lord Ramsbotham (CB)
My Lords, like other noble Lords, I congratulate the noble Baroness, Lady Tyler, on obtaining this debate and for the way in which she introduced it. I also echo her tributes to the Ministers Paul Burstow and Norman Lamb for their work in the mental health post. I agree entirely with her call for a cross-government mental health and well-being strategy, which has been long needed.
When I saw the list of speakers, I knew that I did not need to say anything about learning difficulties and disabilities, as the noble Lord, Lord Addington, was there. Every time he stands up I realise that we are listening to someone who not only uses his experience wisely, but is worth listening to because of the practical things that he always adds. I also welcome the noble Lord, Lord Suri. I was very glad to hear him concentrate on elements of the criminal justice system, particularly Feltham. Not surprisingly, that is what I propose to do as well: concentrate on the criminal justice system.
Before I do, I declare two interests, first as vice-president of the Centre for Mental Health, which has done a great deal of work in the reissuing, in particular, of carefully researched reports, which have provided everyone with a great deal information on the whole system and the problems within it. Secondly, I am chairman of the Criminal Justice and Acquired Brain Injury Interest Group. This is doing a great deal of practical work, and showing up some of the shortcomings in the criminal justice system in identifying and assessing the problems that people have, and what needs to be done about them.
Echoing the noble Lord, Lord Goodlad, I should explain that I was fortunate enough before becoming Chief Inspector of Prisons to chair the hospital at Hillingdon, which had a very large and extremely well run mental health unit. The director said, “You must train as a lay assessor or otherwise you’re no use to this hospital”. I am extremely glad that he did because he gave me an insight on which I have based all my subsequent experiences.
When I took over as chief inspector in 1995, I was extremely alarmed to find that healthcare in prisons was not the responsibility of the National Health Service. It seemed utterly absurd because people came from the NHS and went to the NHS. The staff were not NHS-trained, and I discovered that only 10% of medical officers in prisons were qualified to act as GPs in the National Health Service. I set out to try to do something about it. That aim was achieved in 2003, eight years later. I was very glad that we had quicker-minded people acting for the country during the Second World War.
Fairly soon after that, in 1998, the Office for National Statistics published psychiatric morbidity figures for all our prisons. It produced the figure that the noble Lord, Lord Addington, cited: 70% of prisoners have one or more identifiable personality disorders. That does not mean that they are certifiable under the Mental Health Act, although at least 500 a year are, but it means that there is something wrong. If you can identify it and do something about it, that could mitigate the bad behaviour or whatever it was that led them to commit their crime. It has always seemed to me that the proper assessment of whatever mental health problems people come in with has been sadly missing. It has always been said that treatment in prisons should be the equivalent of treatment in the NHS, but unless the assessment is right, you will get no treatment that is worth the name. The importance of partnership in that is that time in prison is when various organisations could get to grips with whatever physical or mental health problems a person has and use the time to advantage. That must be a public health benefit when people are released.
An improvement that came from the Health and Social Care Act was placing commissioning for offender services under NHS England. Having heard about it, I looked forward to the development of local health and well-being boards on which I hoped the criminal justice system would be properly represented. However, I am concerned about the inconsistency of these boards, and it worries me that they meet only quarterly. If they are to help the criminal justice system in particular, meetings need to be more frequent and consistency between what happens in one health and well-being board area and another needs to be developed.
Having said that, like the noble Lord, Lord Goodlad, I welcome the foundation of the mental health and well-being task force. It is a healthy development in this area. I particularly welcome its children and young people sub-committee. The five all-party groups that are studying children and young people’s mental health and emotional well-being are going to meet the sub-committee. That is particularly relevant for one of my current concerns, which is that I do not think that all is well within the criminal justice system. I am currently very concerned that due attention is not being paid to the mental health needs of detained children. That is confirmed by the proposal to build a secure college for 320 of them under the age of 18 in which the emphasis is to be on education which, it is alleged, is the key to a reduction in reoffending. What is being proposed is totally at variance with the advice of those who have any experience of the characteristics, problems and needs of the children who will be sent there. The scant acceptance of this advice is reflected in the insistence by the Secretary of State for Justice that educational outcomes are more important than the selection of suitable staff. How wrong he is: staff are absolutely key to anything that is done.
I have two other concerns. One is purely to do with the criminal justice system and the other with the linkage between that system and people outside it with mental health problems. My first concern is probation. There are 200,000 people currently serving community orders. Only 20% of CCGs believe it is their area team’s role to commission healthcare for those on probation. We have just got that figure through the Freedom of Information Act. Only 1% of CCGs are currently directly funding general healthcare in probation; 40% have nothing to do with it; the remainder have some association with it. Only 6% of mental health trusts provide services for probation and the majority of that takes the form of a half-day advice clinic once a week. That is wholly inadequate and something must be done, somehow, to connect the Ministry of Justice and the Department of Health to improve support for those on probation, who have exactly the same characteristics as the Office for National Statistics showed in 1998 for those in prisons.
My second concern is employment, which is absolutely key to the rehabilitation of any offender but is also crucial to the future well-being of people with mental health problems. Last week, I attended the launch of a report by the Mental Illness and Employment Task and Finish Group, which addressed the serious inequality of employment outcomes for people with and without mental health problems. It is a very good report and Norman Lamb spoke extremely well at its launch. I welcome the recent introduction of CCG outcome indicators on employment rates for people with mental illness because this will, at least, draw the facts to people’s attention. I welcome the Commissioning for Quality Innovation targets for supporting adults who are in contact with mental health services. This is an unresearched area and we need to do much more if we are really going to provide mental health services in this country that are worth the name.
Baroness Chisholm of Owlpen (Con)
I thank the noble Baroness, Lady Tyler, for initiating today’s debate and join your Lordships in congratulating my noble friend Lord Suri on his maiden speech.
In my lifetime, mental health services have gone through a radical transformation, perhaps more than any other part of the health system. When I started nursing, people with mental health problems were usually treated in large institutions. Today, as your Lordships know, care is focused mainly in the community. Multidisciplinary teams care for people in their own homes. Admissions are in small specialist units and for those requiring long-term care there are small residential units. This is, of course, the way forward, but unlike most other health complaints, mental health has its own very special problems. When those with mental health issues suffer an episode, they require immediate attention. An appointment one week or even a few days later can be too late and lead to disastrous consequences. Acute in-patient service provision has remained a challenge throughout the country, as has community care. With people being treated mainly in the community, the number of in-care beds has decreased, causing an increased number of out-of-area placements at substantial cost to authorities and with lengthy travel, leading to extra cost to clients and their families. But there is good practice going on that is making a considerable difference in certain areas and I would like to share two of these with your Lordships today.
I am closely involved with a charity called the Nelson Trust which has facilitated two women’s centres, in Gloucester and Swindon, treating clients with substance abuse. As the Corston report stated, more often than not these women have a history of mental health issues. The women whom we are seeing at the centres are those who have suffered trauma in their life, leading to depression, self-harming and personality disorders, and this in turn has led to substance misuse. Many of our clients have served custodial sentences and been in constant trouble with the police. When they are referred to us, the Nelson Trust can be their last chance to avoid a prison sentence.
We have heard from the noble Lord, Lord Ramsbotham, about the importance of looking after people with these problems in our society. In July 2014, Theresa May delivered a speech outlining the importance of ensuring that people with mental health problems are identified and diverted from the criminal justice system into appropriate healthcare and support service providers. The psycho-educational group programme at the Nelson Trust responds to these difficulties along with emotional and practical support not only to the client but, more often than not, treating the whole family. This brings huge financial savings to the community and treats the multiple problems that mental health can bring under one roof. The centres are closely involved with the police, probation and healthcare professionals, magistrates and housing providers.
In Cambridgeshire, our police and crime commissioner, Sir Graham Bright, facilitated a Cambridgeshire and Peterborough mental health crisis care concordat. This landmark agreement sets out how agencies that deal with people suffering from mental health problems will work together to support those experiencing a mental health crisis. Improved information-sharing, prevention and early intervention were just some of the commitments made in the declaration.
Those are just two examples of joined-up thinking which has brought a difference in these communities to both those suffering from mental health problems and the professionals who come into contact with them. Implementing known good practice that already exists provides good integrated mental health care, saves time and money and expedites the care that can be available. The King’s Fund stated in September 2014:
“Cultural change is as important as funding in transforming mental health”.
How true this statement is.
Mental health still carries a stigma, yet one in three of us will come into contact with mental health problems in our lifetime. It can affect people of any age, any socioeconomic group and is hugely destructive not only to those suffering mental health issues but to their families as well. We are at ease discussing other health issues, quite often intimate ones, but will rarely discuss mental health issues. This must change; mental health should be treated as a core public health issue so that it will be as normal for everyone to look after their mental health as it is to look after their physical health. The public health workforce must see mental health as one of its core responsibilities. The voice of the mental health community is finally being listened to and, as we are seeing today, the issues are being debated, but collaboration between commissioners, providers, service users, academics and clinicians and the justice system is still too rare.
Mental health cannot be considered in isolation and can rarely be separated from physical health. Therefore, as with most practices within the NHS, it requires a joined-up approach involving multiple stakeholder groups. A reduction in the number of people across the UK developing mental health disorders is surely the only way that mental health services will adequately cope with future demand. The case for more preventive work is therefore undeniable.
Arguably, the onus today is on GPs to run initial care and give treatment, instead of referring patients on to the appropriate professional. However, as one noble Lord has stated, some GPs have said that they felt out of their depth. Is this partly due to the downplayed role of psychiatric social workers, daycare workers and community psychiatric nurses? Could an acute episode be avoided if respite or suitable community care were more readily available when someone felt an episode building up, thereby saving considerable frustration and a feeling of helplessness for the client, as well as saving the considerable resources required for treating an episode once it reaches crisis proportions?
These are an inadequate few words on a massive subject that affects people from birth to death, leaving in its wake a feeling of helplessness, fear, frustration and loneliness among all those it touches. We must feel confident that, when seeking help for mental health problems, the appropriate healthcare experts will be immediately available to give us the appropriate treatment and care in the appropriate place.
Baroness Janke (LD)
My Lords, I, too, am grateful to the noble Baroness, Lady Tyler, for initiating this debate. I shall focus on the significant numbers of people with multiple and complex needs. They might be street drinkers, homeless people, an aging drug-using population; people with wide-ranging mental health issues, including complex trauma histories; many women trapped in the sex industry with significant multiple needs; and young people, including 16 to 17 year-olds. They might be individuals with serious health-related needs and long-term conditions who have a range of complex needs, some of whom are at the end of their lives, as well as increasing numbers of people who are unable to be housed due to the complexity of their needs and the risks associated with their behaviour.
These people often have at least three of the four needs areas: mental ill heath, homelessness, drug and alcohol misuse, and offending. They are also likely to have other significant factors such as: poor physical health, including long-term conditions; experience of complex trauma in childhood or early years; and experience of domestic abuse. This group is often the farthest away from services or only comes into contact with services when in crisis; they perhaps come into contact with the police, A&E or mental health crisis teams. In addition, gaps in services, or the way that services are provided, can mean that, in the worst cases, help is not available, or that people are passed round the system, having to deal with several different agencies—or, worse still, that they get into the revolving-door syndrome where they are constantly repeating their experiences and not receiving the support to ever move forward.
Mental health needs in this area are often undiagnosed, undisclosed, untreated, masked and compounded by other needs. It is an area where people have problems that are often considered too entrenched or too complex and they have no one to turn to. It is an area where traditional ways of working are simply not working. It is understandable that many of these people feel excluded and without hope. The conventional services are not addressing their needs but are being used in an ineffective and costly way. People with long-standing mental health needs are not well served by repeatedly ending up in A&E or in police custody. As many experts have said, the services provided for those with multiple and complex needs have to change. Indeed, the noble Lord, Lord Patel, said today that it is the services that are hard to reach.
I would like to highlight one project today that is particularly focused on this area of need; it is called the Golden Key project. The idea is that this golden key will unlock services. It consists of a partnership board, resulting from a Big Lottery Fund bid by a consortium of agencies working with Bristol City Council. The project helps people to drive their own recovery by providing support, by reconfiguring services, and by enlisting the help of people who have had the experience of living through similar issues and who have come through it to regain their own lives.
The project is at an early stage. As I said, it is run by a broadly based partnership on which the full range of interested groups are represented, including agencies that provide services, commissioners, clinical commissioning groups, peer mentors who have real experience, business, and city leaders who are championing this project. Key elements include a group of 300 individuals who sign up to the project “walking the journey” with a lead co-ordinator at a pace that is right for them. At the heart of the scheme are the peer mentors, who bring their own lived experience to support, and to inspire hope. Golden Key agencies and services are pledged to work together to make services accessible and sympathetic to needs.
Innovative aspects of this project include small personal budgets that encourage staff and their customers to think carefully about which practical measures might create early successes. There is a “telling your story once” website, with access controlled by the client, so that people do not have to repeat their personal information and story. One symptom of the current service is that an individual seeking support may have to tell his or her story to a range of different agencies. This website tries to bring services together and shape them to the individual who needs them. There will be a psychologically informed environments approach to deliver more effective services through a deeper understanding of clients’ needs. There will also be training and action learning to embed change.
Very many of us are aware of this complex area of need and care about these most deprived and excluded people. It is essential that these people’s acute need is fully recognised and that we look at ways of building on national and international examples of good practice. Through this, we must find ways of unlocking the future for a group of people who often do not believe that they have one.
Lord Bradley (Lab)
My Lords, I also congratulate the noble Baroness, Lady Tyler of Enfield, on securing this very important debate and on her very effective and wide-ranging opening contribution to it. I also congratulate the noble Lord, Lord Suri, on his excellent maiden speech. He will clearly be a very welcome addition to your Lordships’ House.
Mental health has rightly risen up the political agenda significantly in recent years. It is timely to take stock of the current issues and policy developments that have taken place during this Parliament. I declare my interest as a trustee of the excellent Centre for Mental Health, which undertakes superb work in this area.
Let us first consider further some background facts and figures. I make no apologies for repeating what many noble Lords have already mentioned. Mental health problems affect 23% of the population at any one time, the most prevalent of which are depression and anxiety at 17% of the total. As we have heard, the economic and social costs of mental ill health are estimated to be £105 billion annually. As the NHS Five Year Forward View points out, this is roughly the cost of the entire NHS budget. Mental ill health accounts for 23% of all ill health—more than heart disease, cancer and diabetes—and causes as much ill health among working-age people as all physical illness combined. Some 10% of children aged five to 15 have a mental health problem. Three-quarters of people with depression receive no treatment at all. A third of people with a long-term physical illness also have a mental health problem. This costs the NHS an extra £10 billion in extra prescriptions, hospital admissions and more expensive treatments.
As we have heard, nine out of 10 prisoners have a mental health problem, and mental health research funding—as we have heard again—is appallingly low. As the organisation MQ points out, the scale of mental health research is not proportionate to the burden of disease. The spend on mental health research is just 5.5% of the total research spend in the UK, despite the fact that mental health problems, as we have heard, affect around one-quarter of the population in any one year. MQ further points out that a major challenge in the mental health funding landscape is that, in contrast to the other major health conditions, public funding of mental health research is virtually non-existent. For every £1 that the Government spend on cancer research, the general public invest £2.75; for heart and circulatory problems it is £1.35. For mental health research, the figure is 0.003p. I am not arguing against such public investment in other disease groups; I am simply putting mental health research in that broader context. Like the noble Lord, Lord Patel, I look forward to the Minister’s response on that point.
Against that backdrop, what have been some of the key policy pledges made by the Government on behalf of those suffering with mental health problems, and what appears to be the current position on each? First, there are new access standards for mental health, which are clearly welcome. Announced in October 2014, they include, from April 2015, waiting-time standards for improved access to psychological services, and early intervention in psychosis services. The Department of Health’s five-year plan to improve access to mental health care pledged to follow this up with further standards, for example in urgent care and in child and adolescent mental health services. This must be completed to ensure that we have genuine parity of access to mental health care, as we do to urgent and elective care for a range of physical illnesses. There must also be comparable entitlement to NICE-approved interventions to ensure that there is no compromise on quality. Such entitlements are essential to delivering parity of esteem. However, I noted carefully the views of the noble Lord, Lord Patel, on that point.
Secondly, on mental health care funding, data suggest, as we have heard, that NHS spending on mental health services has fallen in real terms each year from 2011 to date. This is putting services under great pressure, leading to disinvestment in effective interventions such as crisis resolution and home treatment, and placing extra pressure on hospital beds. It is even leading to bed closures where there is often already underprovision. Local campaigns, such as those in Waveney and other areas of the country, have been initiated to protect vital local mental health services. I would be grateful for the Minister’s views on that situation, as well as for his view on the Royal College of Nursing’s view that there are now 3,300 fewer posts in mental health nursing and 1,500 fewer beds than in 2010. Planning guidance recently published by NHS England asked CCGs to secure real-terms increases in mental health spending for 2015-16. It is vital that this is implemented and that accurate records are kept of spending on mental health services for adults and children.
Thirdly, on crisis care, the crisis care concordat was published a year ago, as we have heard, and is welcome. It sets out the standards expected in all local areas. The deadline for localities to produce crisis care declarations has now passed. These should be followed up with local action plans to implement agreed measures. The tracking map shows that all areas have now made declarations but that few have action plans to go with them. It is unclear how local organisations will be held accountable for achieving progress and how it will be monitored. I hope the Minister will be able to elaborate on that point.
Next comes liaison and diversion, in which I have a particular interest. NHS England recently announced the expansion of the national programme of liaison and diversion services to cover half the population of England. This is welcomed but we must ensure that it is extended nationwide by the committed-to date of 2017. However, there is also a need for CCGs and other commissioners to commission services to which people can be diverted to make the investment in such services as effective as possible. I hope that the Minister can reassure us on that point as well.
Finally, on employment, the Government have recognised that the Work Programme is not offering adequate help to people with mental health problems, and they have invested in a pilot to trial the adaptation of the individual placement and support approach for people with common mental health problems. This work needs to inform the future of the Work Programme. I also commend the report that has been mentioned, published on Tuesday, on addressing the serious inequality of employment outcomes. It makes very clear recommendations on how to improve employment opportunities for people with severe mental health problems, such as schizophrenia, about which the noble Lord, Lord Goodlad, spoke so eloquently earlier.
In spite of those initiatives, which are clearly welcomed, there remain many weaknesses and concerns. We have already talked about the real-terms reduction in funding and about the fact that people with mental health problems have been adversely affected by continued weaknesses in the work capability assessment and, in some cases, by the use of benefit sanctions. We have heard about schools being given little support in promoting mental health and the removal of well-being from Ofsted inspections. We have also heard of the major concerns in children’s mental health services, which have experienced particularly large cuts. Last year, two-thirds of councils and three-quarters of CCGs cut or froze CAMHS spending. A recent Parliamentary Answer showed that the aggregate PCT/CCG expenditure on CAMHS fell in real terms from £758 million in 2008-09 to £717 million in 2012-13, and I suspect that it has continued to fall. The position is exacerbated by cuts in youth services, many of which have a positive impact on well-being and prevent the emergence of later problems.
Finally, what should be done to ensure that these situations are addressed? This afternoon we have heard many good examples of new initiatives. We must continue to explore ways of making the NHS constitution fairer, including a wider range of access standards and entitlements to NICE-approved interventions. We must consider revising payment systems for all mental health services to put mental and physical health on an equal footing. We must ensure that the NHS, public health and social care outcomes frameworks and the quality and outcomes framework for GPs properly represent mental health priorities. We must invest in cost-effective interventions—which are currently undermined by a postcode lottery—for, for example, perinatal mental health care and parenting programmes, and, crucially, we need early intervention in psychosis and individual placement and support.
My time is almost up but that list is not exhaustive. The quality of this debate shows how many initiatives people understand and want to progress through the development of mental health services. Whether we are talking about adults or children, they need and deserve that support, and I hope that this high-quality debate will help to progress that agenda.
Baroness Jolly (LD)
My Lords, I thank my noble friend Lady Tyler for tabling the Motion for this excellent debate. It has really been a series of mini-debates. We have had experts of all sorts bringing their experience to bear on subjects such as parity of esteem, maternal health, dual diagnosis, children and young people, prisons and public health, to name but a few.
Mental illness can emerge at any age and can have highly significant impacts across much of the life course for the individual, their family and the community. The noble Lords, Lord Goodlad, Lord Farmer and Lord Bradley, among others, have outlined some statistics—and I have some more. We know that at least one in four people will experience a mental health problem at some point in their life. Mental health problems are the single largest cause of disability in the UK, contributing up to 22.8% of the total burden, compared to 15.9% for cancers and 16.2% for cardiovascular diseases. It is estimated that the wider economic costs of mental illness in England are, according to anyone’s figures—and we have heard several this afternoon—enormous.
The noble Lords, Lord Patel and Lord Goodlad, raised the issue of parity of esteem. This has been a game-changing issue. The Government’s commitment to prioritising mental health is encapsulated in the principle of parity of esteem—equal priority for mental and physical health—which was set out in our 2011 mental health strategy, No Health Without Mental Health. This commitment to parity was made explicit in the Health and Social Care Act 2012. Many noble Lords here will remember that vote well and many will be grateful for it.
The 2014-15 mandate to the NHS sets an explicit target for NHS England to make measurable progress to ensure that,
“everyone who needs it has timely access to evidence-based services”.
My noble friend Lady Janke referred to the challenges posed by those who only attend emergency and crisis services. In October 2014, NHS England set out its vision on the future of the NHS in its Five Year Forward View. This recognises that,
“the NHS must drive towards an equal response to mental and physical health, and towards the two being treated together”.
As part of that commitment, for the first time ever, waiting time standards will be introduced in mental health services in 2015-16. My noble friend Lady Tyler referred to these. They will include: 75% of people referred to the Improving Access to Psychological Therapies programme will be treated within six weeks of referral, and 95% will be treated within 18 weeks of referral; and at least 50% of patients experiencing a first episode of psychosis will be treated with a NICE-approved care package within two weeks of referral.
On the subject of child and adolescent mental health services, my noble friend Lord Addington spoke movingly about the fact that, if people are different, mental health problems can follow them. He spoke about dyslexia, dyspraxia and autism. It is estimated that 50% of mental illness in adult life begins before the age of 15 and that 75% of mental illness in adults starts before the age of 18. Early intervention is known to reduce not only the incidence, duration and severity of lifelong mental health problems, but also the cost of mental health problems to the economy. We will invest £30 million a year over the next five years to improve services for young people with mental health problems. We are also investing £54 million over the period 2011 to 2015-16 in the Children and Young People’s IAPT programme, to transform child and adolescent mental health services. In August we set up the Children and Young People’s Mental Health and Wellbeing Taskforce, to focus on innovative solutions to improve outcomes for children and young people’s mental health. It will report to Ministers in spring this year.
My noble friend Lord Storey brought his experience as a head teacher to the debate. I can tell him that I have recently spoken to the Care Minister, Norman Lamb, on the issues that he mentioned, about how things will work and the work that will be going on with the Department of Health to try to nail some of those problems.
Mental health crisis care is crucial. People in mental health crisis need speedy access to safe and compassionate care in the right environment. My noble friend Lady Janke gave us an example of a multidisciplinary, multiagency approach in Bristol—the Golden Key approach. We know that an effective response can often prevent an in-patient admission, which is disruptive to an individual’s life and their well-being, as well as costly to the taxpayer. It can also help to avoid totally unacceptable admissions a long way away from people’s homes. The first national crisis care concordat was published in February 2014 to improve service responses to people in mental health crisis and, in particular, to keep people in mental distress who have committed no crime out of police cells. The concordat—the noble Baroness, Lady Chisholm of Owlpen, spoke about the Cambridge one—is a national commitment for agencies to work together to support people in crisis to find the support that they need.
The 2014-15 mandate to NHS England specifies that NHS England must make rapid progress, working with clinical commissioning groups and other commissioners, to help to deliver on the shared goal to have,
“crisis services that, for an individual, are at all times as accessible, responsive and high quality as other health emergency services”.
That picks up on the question asked by the noble Lord, Lord Patel. I can report that, as of 22 December 2014, every local community now has its own local crisis care declaration in place. Local action plans, most of which are expected in the first quarter of 2015, will make sure that improved crisis care is embedded in services for years to come. I have too many responses to contain in this speech, so I will use this opportunity in answer to the noble Lord’s question on how these will be followed up and monitored to say that that will go out in a letter that I shall send to all Peers.
On offender health, my noble friend Lord Suri brought up the important issue of mental health in prisons. I congratulate him on his maiden speech and look forward greatly to his work in your Lordships’ House. I can assure the noble Lord, Lord Ramsbotham, that the NHS provides treatment and care according to clinical need, so offenders, irrespective of gender, should receive the same range and quality of treatment and services as anyone else. Offenders within the criminal justice system—whether in the community or outside—with mental health needs should have their treatment delivered in the most appropriate setting, whether in prison or in the community. We should listen to his wise words on the issue of young offenders’ mental health. We have committed £25 million to introduce a new standard service specification of liaison and diversion services in England to identify and assess the health issues and vulnerabilities of all offenders when they first enter the criminal justice system. Prison healthcare has improved significantly since the NHS first became responsible for commissioning it in 2006 and it continues to improve. But we should not be complacent. The noble Lord, Lord Ramsbotham, also mentioned health and well-being boards. These were set up locally to meet local needs, so the frequency of their meetings will be determined locally, not nationally.
On mental health information, the lack of mental health data is an issue that goes to the heart of equal priority for services. We do not have the same level of information on mental health services as we do for physical health. Information that has proved so critical in driving improvement and service change in the rest of the NHS is either absent or incomplete for mental health. We are driving forward plans to address gaps in mental health information on prevalence, waiting times and access, outcomes, spend, uses of out-of-area placements and restraint. To further the parity agenda, data from across the health and care system has, for the first time, been brought together on the NHS Choices website. Key in this is the inclusion of a specific mental health section. This level of data will help to facilitate evidence-based decision-making, drive up quality and standards and ensure genuine accountability for the services provided. It will, in time, create the most transparent mental healthcare system in the world.
The noble Lord, Lord Goodlad, raised the issue of schizophrenia and questioned why little progress had been made on schizophrenia research. More than £400 million is being invested over the spending review period to make choices of psychological therapies available for those who need it. We are investing in improving provision, including for those with severe mental health conditions.
Data are also vital to research, helping us to provide the evidence that we need to transform services. Investment in mental health research by the National Institute for Health Research—the NIHR—has nearly doubled in the past four years, from £40 million in 2009-10 to £72 million in 2013-14, and we will continue to support the work of the NIHR and the network of specialist clinical research facilities in the NHS.
From September 2014, more than 800,000 people with the most complex physical and mental healthcare needs are benefiting from the Proactive Care Programme. This is being delivered through an enhanced service to the GP contract. Many of these people will have complex physical and mental health needs and this initiative will ensure that they get personalised, joined-up care and support, tailored to their needs.
NHS England is working with commissioners to make mental health a bigger priority, with better integration of physical and mental healthcare in primary care and, indeed, in all settings. Improving the diagnosis of mental illness is one of four national goals for 2014-15. Providers will be rewarded for better assessing and treating the mental and physical needs of their service users.
The issue of training for GPs was raised. The Royal College of General Practitioners has a programme around training. However, there are two issues: one is the training of new GPs before they go out and practise; the other is the ongoing training of GPs in all the new developments. The noble Lord, Lord Bradley, raised the issue of the mental health workforce. Health Education England has increased training places for mental health nurses by 3.2% for 2015-16.
As for mental health unemployment, getting people back to work is a priority for the Government. Jointly with the Department for Work and Pensions, we commissioned external policy advice from RAND Europe on how we can achieve better outcomes for people with common mental health problems. Based on the recommendations put forward this year, we are taking forward a number of feasibility pilots to explore the most promising and evidence-based approaches.
My noble friend Lord Addington addressed the issue of ensuring awareness among healthcare professionals of potentially vulnerable groups. As the mandate to NHS England makes clear,
“everyone who needs it should have timely access to evidence-based services”,
including people with autism and learning disability. In line with the Equality Act, we expect all service providers to make reasonable adjustments so that disabled people are not placed at a disadvantage compared with non-disabled people.
My noble friend Lady Tyler raised the issue of Time To Change, the country’s largest anti-stigma and anti-discrimination mental health campaign—indeed, several other noble Lords mentioned it—which the department currently funds by up to £4 million a year. Between December 2012 and December 2013, we have seen a 20% decrease in the number of life areas in which people experience discrimination. On discrimination for black and minority ethnic patients, this Government are committed to tackling inequalities in access to mental health services. The commitment to reduce inequalities is in our action plan, Closing the Gap. The 2014-15 mandate to NHS England makes it clear that everyone should have access to the mental health services that they need.
On the issue of mental health and perinatal health for mothers, the mandate to NHS England includes an objective for NHS England to work with partner organisations to reduce the incidence and the impact of post-natal depression through earlier diagnosis and better intervention and support.
On the budget, mental health funding is not ring-fenced. However, we expect commissioners to demonstrate parity of esteem when agreeing financial statements. Aggregate CCG expenditure is not yet available for 2013-14, but NHS England advises that total mental health spending in 2013-14 was £11.3 billion with an estimated £11.6 billion planned for the following year—an increase of £302 million.
There are many other issues that I will write to noble Lords about. I am proud of the Government’s record on mental health, of the role of my honourable friends Paul Burstow and Norman Lamb in the other place and of the commitment and leadership of the DPM. But as the noble Baroness, Lady Tyler, has highlighted, there is still more to be done. I would not want to suggest any complacency on the part of the Government on this vital issue. I feel confident that, whatever May brings us, Members of your Lordships’ House will keep the feet of the new Government well and truly to the fire on issues of mental health. I particularly thank the noble Lord, Lord Farmer, and the noble Baroness, Lady Tyler, for giving us some ideas for the new Government to start with.
Baroness Tyler of Enfield
My Lords, this has been an excellent debate drawing on the wealth of expertise, knowledge and first-hand experience of all the speakers. I thank all noble Lords who spoke and especially commend my noble friend Lord Suri for his excellent maiden speech. I also thank the many local health organisations that provided me with briefing; I particularly thank Mind for its help.
I do not think that anyone who listened to the debate this afternoon could be in any doubt about the strength of feeling on this issue, the importance of mental health to the country’s well-being or indeed the scale of the challenges ahead. Those challenges are for central government, but also for the NHS, local councils, the voluntary sector, communities and, indeed, families.
I leave noble Lords with one thought: many speakers this afternoon, myself included, talked about or implied that the problem was around the issue of institutional bias against mental health within the NHS. I feel that that sort of culture has started to change, given that one quarter of the population in this country experience mental health problems at one time or another, a quarter of all managers in senior leadership positions have a mental health background and a quarter of all the thinking and doing time in the NHS is spent on mental health.