Mental Health: Out-of-Area Placements
(9 years ago)
Commons ChamberRead Hansard Text Read Debate Ministerial Extracts
Norman Lamb (North Norfolk) (LD)
It is a great pleasure to be able to raise a very important issue for debate, albeit three hours earlier than expected. It is good to see the Minister for Community and Social Care taking his seat.
I want to raise an issue of profound importance. It is a practice which I think is intolerable but which carries on every week of the year and probably every day of the year: the shunting of people around the country, sometimes a long distance away from home, at a moment of mental health crisis. Typically, someone at a moment of acute crisis would be taken into hospital but there would be no bed available for them, so they would be taken away somewhere else in the country. There are numerous stories of people being taken hundreds of miles away from home on a regular basis.
Such practice would never be tolerated in physical health services. Let us imagine, for example, someone who had had a stroke or with a heart condition being taken by ambulance and being told, “I’m sorry, there’s no room at the local hospital. We’re taking you to Cumbria from Norfolk.” It would be an outrage. It would be regarded as a scandal, so it does not happen—yet it happens every week of the year in mental health. I regard that as discrimination at the heart of our NHS and it is one of the very many examples of how people who suffer from acute mental ill health are disadvantaged by the system.
Incidentally, I make no criticism of any individual Government; this practice always happened, but there has been a rise in the number of instances, which I will come to in a little while. In many ways, someone suffering from mental ill health does not get the same right of access to treatment at a moment of need as someone with a physical health problem. If any of us in the Chamber stopped and thought about it for a moment, we would conclude that we cannot begin to justify that, and that there must be a programme designed to achieve genuine equality of access to support at that moment of need.
Mr Mark Williams (Ceredigion) (LD)
I congratulate my right hon. Friend on securing this debate about an area in which he has done so much work to date. The debate is about out-of-area mental health placements, but does he agree that there is also a huge problem in some of the vast health board areas—in our case in Wales—where rurality is an important factor? For instance, the closure of the Afallon mental health ward in Bronglais hospital in Aberystwyth means that constituents of mine have to travel or be sent 50 miles away—not over the easiest terrain—to the Morlais ward in Carmarthen. There is a huge problem across the country, but there is a great problem in those great geographic areas too. I do not expect my right hon. Friend to comment on the details of the Welsh national health service, but I am sure the problem is replicated in English health areas.
Norman Lamb
I am grateful to my hon. Friend for raising that. He makes an extremely important point. I will come on to address it in more detail later.
There is, for example, evidence of an increased risk of suicide if people are treated a long way from home and family and friends who struggle to visit them. The idea of care close to home is incredibly important in mental health. We should, as far as possible, seek to care for people at home, not take them into hospital unless that is unavoidable. There are times when that is necessary, and as far as possible there should be a place close to home.
Mr Williams
I know that what I am about to ask is not a central point of my right hon. Friend’s debate, but does he agree that one of the unacceptable outcomes has been the increased use of the police and police cells for holding people overnight? That has been the situation in my constituency.
Norman Lamb
That is a shocking practice. I applaud my hon. Friend for the work that he has done on it in his area. The idea of putting someone who is suffering an acute mental illness into a police cell, which is defined in the legislation, unbelievably, as “a place of safety”, is bizarre and ought not to be tolerated. I am pleased that the Government have indicated an intention to legislate, in effect to eradicate the problem completely for under-18s and to make it an exception for adults. We managed to reduce the numbers in England by 50% in the past two years, which was considerable progress, but we need to go much further and bring an end to an unacceptable practice.
It is interesting that where local passion and drive exist, amazing things are possible. In our capital city, London, last year around 20 people in total ended up in a police cell, whereas in Sussex the number was over 400. That demonstrates that with real drive from both police and mental health services, practices can be changed and people’s lives can be made better. My hon. Friend is right to persist with the issue in Wales, just as I have tried to do in England.
Kevin Foster (Torbay) (Con)
I congratulate the right hon. Gentleman on securing the debate and on the work that he has done to bring the issue to the fore. A police cell should be for someone charged with a crime, not for someone who is unwell. Does he agree that to some extent the problem could be overcome with better co-ordination? I had a case in my constituency where a local treatment unit was full so a person was placed in Maidenhead. We then discovered that there was someone from Maidenhead in the local treatment unit in Torbay and arranged a swap.
Norman Lamb
Such a story makes one weep and leaves one feeling that there is a degree of incompetence somewhere. I will come to that point. Much of what I want to see happen can be done by better organisation, rather than by providing more money. I strongly believe that we need more investment in mental health services, but a lot can be done just by organising things much better.
Tom Brake (Carshalton and Wallington) (LD)
Will my right hon. Friend commend the work that South West London and St George’s Mental Health Trust has done with a number of local authorities in the area, including mine? The police work with a nurse, to ensure that if the police are dispatched somewhere where a person has a mental health problem, there is someone who is able to assess them immediately and ensure that they go to a place of safety, as opposed to going to a police cell.
Norman Lamb
Absolutely. My right hon. Friend is talking about something called street triage—I am sure that the Minister is familiar with it—which we introduced in many areas of the country over the past two to three years with a bit of pump-priming grant. Some pioneering areas, such as Leicestershire, just went ahead and introduced it before the national pilots started. The evidence is dramatic. Where we have that collaboration between the police and mental health services, with a nurse embedded in the police team, we achieve amazing results. We completely reduce the number of people being taken in under that legislation, because the nurse can find alternative solutions or provide care at home. Where it is necessary to take somebody to a place of safety, the numbers having to go into police cells falls dramatically. That innovative work was very much part of the crisis care concordat that I pioneered when a Minister, the aim of which was for the first time ever to set standards in mental health crisis care.
Mr Mark Williams
It would be wrong not to acknowledge in my area the Dyfed-Powys police and how the health board has embarked on such an initiative. My right hon. Friend will acknowledge that areas such as mine face the challenge of rurality and making those services available where they are needed. There is still a fear that all too often the need is not met.
Norman Lamb
I agree. My own county of Norfolk, with its widely dispersed rural communities, suffers from the same challenges. Sometimes having a nurse in a car with a couple of police officers does not work in a big rural area. However, we can do other things, like having a nurse embedded in the police operations room so that whenever an issue arises they can speak immediately by telephone or, if necessary, get a resource to the scene. Depending on the geography, there are ways of dealing with those challenges. We need to be much smarter in doing that. I applaud the innovation across the country.
Our whole approach in the crisis care concordat was rather different from the traditional Government approach, which is sort of to impose a straitjacket. The crisis care concordat said, “These are the principles. You come up with your plan for implementing them, working with the police, mental health services and the local authority, in a way that works for your locality.” That generated the most amazing degree of innovation across the country, and real progress has been made. Although I initiated it, I have enormous admiration for the people on the ground who got on and did it. It was inspiring.
Norman Lamb
I will give way, but then I really ought to make some progress.
Tom Brake
I want to return to the point my right hon. Friend started with. We had an issue in Sutton where the mental health facility is based on what had been the Sutton hospital site—it was shut down mainly because Legionnaires’ bacteria were discovered. Patients now have to travel to Springfield hospital. As we see more people being treated at home, which is what we want, and therefore fewer people in acute crisis, how does he deal with the fact that, because hopefully fewer people will need to be treated in specialist centres, there is likely to be a smaller number of them?
Norman Lamb
My right hon. Friend makes a good point. Again, it means that we need to think afresh and innovate. The third sector has been very good at coming up with concepts such as crisis houses, where at quite low cost a facility can be provided in a locality where someone can go at a moment of crisis. They therefore might not need a formal hospital admission, and it might be a much more therapeutic place to be as they get through their crisis. I recently visited the Hertfordshire Partnership NHS Foundation Trust, which, in addition to crisis houses, has host families that someone can go to be with, if that is appropriate, for a week or however long is necessary. That might be exactly what is needed, rather than the cold, clinical environment of a hospital ward. That sort of innovation is what we need in order to ensure that we have services that meet patients’ needs.
I want to share with the House the testimony of a constituent who has experienced an out-of-area placement. It has been anonymised, for obvious reasons, but it is very powerful none the less. It is quite shocking. It reads as follows:
“I was admitted to accident and emergency at Norfolk and Norwich Hospital on a Wednesday afternoon, following a suicide attempt. I regained consciousness the following day, having been transferred to the Acute Medical Unit, and it was quickly decided that I needed to be admitted to a mental health ward.
I had previously been on Glaven Ward at Hellesdon.”
That is the mental health hospital in Norwich. My constituents continues:
“At this point I was very woozy, suffering from a dangerously low mood, and angry that my suicide attempt had failed. I was at grave risk of making another attempt on my life. Throughout the Thursday and Friday efforts were made to find a mental health bed.”
That is what happens in the system.
“My parents were frantically trying to find out what was happening, as they were desperate for me to be looked after locally. For a time we were told that I would be going back to Glaven Ward at Hellesdon, but the news kept changing between there and a unit in London.”
London is between 120 and 130 miles away from Norwich, and further away from my constituent’s home.
“I was expecting to go to Hellesdon on Friday morning, but we were then told later that day that I would be going to south London. During the Friday, I twice walked off the ward and out of the hospital, without my absence being noticed, and went down to the Watton Road”—
which is near the hospital—
“with the intention of walking in front of a bus or a lorry. The main reason I didn’t go through with it was that I did not want the vehicle to swerve into an oncoming car and cause death or injury to someone else.
Meanwhile, my parents resorted to contacting the crisis team, as they could not get any information from the bed team. A member of the crisis team took responsibility for finding out what was happening and he was able to let me and my parents know that I would be transported to south London later that Friday evening.
Finally, after more uncertainty”—
this is really shocking—
“two men arrived to take me to London. At 10 pm, feeling suicidal, frightened and confused, I got into the back of a private ambulance (which was no more than a pretty austere minibus) and was driven away from the Norfolk and Norwich Hospital. Throughout the three-hour drive, I was spoken to just once by one of the two men, and felt more like a prisoner being transported than a patient.”
That is the way our NHS deals with someone who is acutely ill. It is really shocking. It ought not to be accepted. My constituent went on:
“At 1 am, by now completely disorientated, I arrived at the front door of the mental health unit in south London. After lots of knocking at the door, someone answered, and I was handed over with a quick ‘good luck’. I was booked in and shown to my room. I felt isolated and scared. My room was nice, but the unit felt like a prison. The internal doors were like cell doors, and there was a tiny outdoor area, fringed by a high fence with spikes on the top. It was a mixed ward, both in terms of sex and in terms of illness: people with depression and anxiety were alongside those with psychosis, personality disorders and acute problems.”
It is really shocking that a whole load of people with completely different conditions were thrown together like that. It is probably the least therapeutic environment imaginable. That is about containing people, not caring for them, and it ought to be a thing of the past.
Mr Henry Bellingham (North West Norfolk) (Con)
I had a similar case in King’s Lynn, although I cannot go into it because it ended in tragedy, with the individual committing suicide, having previously made an attempt. Does the right hon. Gentleman agree that it is absolutely essential in such cases that there is proper monitoring and supervision of the individual, whose life is obviously at risk during such an episode?
Norman Lamb
It is absolutely critical that that happens —not only monitoring but proper treatment. As I will go on to describe, that is not what happened in this case.
The constituent continues:
“The following morning, I had a meeting with my named nurse. Extraordinarily, it was the only real conversation I had with him until I was discharged back to Norfolk 10 days later.”
That is not therapeutic care—it is neglect. I have asked whether there are any contractual requirements on the private provider who provided that “care” and received a substantial sum of money for it. I have been told that it was understood that there would be therapeutic care but no apparent requirement that that should be undertaken in return for a substantial amount of public money being spent on his care. He goes on:
“The care was unacceptable. It felt as though I was being kept in a holding facility, and my mental health deteriorated, with my suicidal thoughts increasing. In stark contrast to Glaven at Hellesdon, the staff were holed up in an office with a heavy steel door that you couldn’t see into. I was being checked up on every 15 minutes, as I was a suicide risk.
But I rarely had a conversation with a member of staff. My parents came down from Norfolk twice to see me, and were horrified by what they encountered—both the level of care and my deterioration. They were constantly contacting Norfolk and Suffolk mental health trust to try to get me moved back to Hellesdon. The stress made them both ill.”
That shows the impact there is on families as well. He continues:
“Thankfully their persistence paid off, and after 10 days, I was told that I was going to be recalled. I had a brief period of uncertainty, as I didn’t know whether I would be going to Hellesdon, King’s Lynn or Great Yarmouth.
Eventually, I was told it would be Glaven at Hellesdon, and I got into a taxi with a member of staff and was driven from south London to Glaven Ward.
When I arrived there, I cried, mainly through relief. I was greeted with compassion and understanding by the staff, and—after 10 wasted and expensive days—my recovery finally began.”
That experience, sadly, is repeated day in, day out across the NHS. It is a scandal that it continues. One of the things I will put to the Minister when I conclude is that I want his commitment to end this practice, because it is intolerable that it continues in this day and age.
I mentioned cost. An analysis has been done by the national confidential inquiry into suicide and homicide by people with mental illness, which, having looked at 29 providers, says that the cost of out-of-area placements went up from £51.4 million to £65.2 million in 2014-15. That is an extraordinary amount of money to spend on an unacceptable practice, demonstrating that with smarter use of the resources available it should be possible to bring that practice an end.
The national confidential inquiry also found that being treated out of area increases someone’s risk of suicide. The pattern is most apparent in England, where suicides by in-patients and patients recently discharged from hospital have fallen, although suicides following discharge from an out-of-area ward have increased. The annual number of suicides after discharge from a non-local unit has increased from 68 in 2003-07 to 109 in 2008-12. Experts have warned that mental health patients are at the highest risk of taking their own lives in the first two weeks after being discharged from hospital, and these figures confirm that. When we are talking about a risk of people actually losing their lives, surely we have to see the absolute importance of bringing this practice to an end.
I want to refer to a recent report by the Independent Mental Health Services Alliance called “Breaking Down Barriers: Improving patient access and outcomes in mental health”. It says that we must prioritise something that I have argued for consistently—the introduction of comprehensive waiting time standards in mental health so that someone with a mental health problem has exactly the same right of access to treatment as anyone else. It also says that people who end up in an out-of-area placement, sometimes a long way from home, get “lost in the system”; they are almost forgotten about. They are away from the commissioners and the normal provider, and they can sometimes languish in these centres for far too long. That, again, is completely intolerable.
The report also refers to the problem of delayed discharge. It says:
“We have found that between 2013/14 and 2014/15, the average number of days of delayed discharge per month for trusts providing mental health services increased by 22.2 per cent. This indicates that delayed discharges are having an increased impact on patients’ access to appropriate care.”
In other words, if beds are clogged up by people who are ready to leave and go home or to go to another facility, but they cannot because nothing else is arranged for them, then someone else at a moment of crisis cannot get access to a bed and is shunted off, sometimes to a place a long way from home. That is a completely unacceptable practice.
The report refers to children and young people’s mental health services. The Minister will be particularly aware of the acute concern about children being shunted off, often to places hundreds of miles away from home—an intolerable practice. I know that that has happened in the south-west, where there has been a particular shortage of beds for children. A team within NHS England undertook an inquiry that came up with recommendations for eradicating that problem. The taskforce’s report, “Future In Mind”, which we published shortly before the general election, pointed to the absolute need to care for people close to home and to have better crisis support to avoid admissions where possible. Yet the practice continues, and it must be a priority for the Minister to bring it to an end.
One of the things that “Future In Mind” sought to address is the perverse incentive that exists in the system with the awful tiering of care within children’s mental health services. If a child is put into tier 4 from tier 3 because it is judged that they need more acute in-patient care, then the financial responsibility for their care is transferred to NHS England. There is therefore an incentive for local commissioners to push them into the top tier, which is precisely the opposite of what ought to be happening. We ought to be focusing our incentives on preventing deterioration of health, not shunting people into the most acute care, too often away from home. Imagine what it must be like for the parents of, say, a 14-year-old child who is taken to a unit 100 miles or 200 miles away from home. It is really shocking, and I hope that the Government will feel the need to commit to eradicating that practice as quickly as possible.
When the issue came to my attention as a Minister, I asked my officials to provide me with data to find out what was happening around the country. I was confronted by freedom of information requests by campaigning organisations and by news reports of shocking things that were happening in the system, but I had no information on which to base my own judgment. I was told by the officials that they did not collect data on the issue. The Government are operating in a complete fog, and we have to rely on campaigning organisations to make inquiries under the Freedom of Information Act 2000.
Incidentally, I urge the Minister to use what powers of persuasion he has to argue against undermining the Freedom of Information Act. At the moment, a process is under way that runs the risk of doing precisely that. It seems to me that freedom of information is a really important way of holding the Government to account.
I was faced with having no information or data on that practice, so we initiated a process to collect such data. We have now collected those data. They are still in experimental form, but they are better than nothing. The data show that there is extraordinary variation around the country. That brings me back to the point that this is about not just extra money, but good practice. It is about learning from areas of best practice. We now discover that many mental health trusts have no out-of-area placements, but they are funded in broadly the same way as those in areas that have a persistent and unacceptable problem.
There is a three-month delay before the data are published, so the latest data are those from the end of August, but 2,198 people were in out-of-area placements at that time. We are not entirely clear about whether the drift upwards is caused by the collection of more data or by a worsening of the problem. I do not want to draw the wrong conclusion from the numbers, but they certainly do not appear to be going down.
I want to raise with the Minister the issue that the data are incomplete because some private providers refuse to return data. Under their contractual dealings with the NHS, they are obliged to return those data. When I was a Minister, I raised that matter with officials and with the information centre. Surely, it is completely unacceptable. I have no difficulty with a good private provider providing a good service, but they must absolutely play by the same rules as everybody else.
Tom Brake
To return to my right hon. Friend’s earlier point about freedom of information—in fact, there is a case for extending it—is it not right to ensure that private companies doing public work are covered by FOI in exactly the same way? That applies to the health sector, as well as to many other sectors.
Norman Lamb
I agree. There should be a level playing field, which there is not at present. We now have the unacceptable situation that data are incomplete because some private providers refuse to play ball. That leaves one suspicious, because if they do not provide data about how many people are held, it is impossible to hold the system to account or, indeed, to hold such private providers to account. The Minister must find a way to hold those providers to account and to ensure that they return the data they are obliged to provide.
A horrific number of people are still sent a considerable distance away from home. In August, 501 people were sent more than 50 km away from home. Surely that practice is intolerable, given what I have said about the increased risk of suicide, the fact that it does not provide therapeutic care and that it can lead to someone being confined for 10 days at enormous cost to the public purse. It seems to me that this is the most outrageous misuse of public money.
There are areas where that problem is persistently at its greatest. In August, the Devon Partnership NHS Trust had 45 people in out-of-area placements. The caveat is that we do not know precisely where responsibility lies, and whether this is a commissioning or a provider issue. However, that is the local provider, and one would normally expect such people to be in a bed provided by the local provider. The figure of 45 people means that significantly more than one person a day is shunted more than 50 km away from home, which is outrageous.
Mr Bellingham
Has any analysis been done of whether the families have been contacted in such cases? It is incredibly important that one strand of support for these patients is through their families. What percentage of cases involve families being informed, having given permission for the patient to be moved?
Norman Lamb
We do not have that information—the data are very basic—but that matter is crucial. I imagine that communications often fall down when urgent referrals to another location take place.
I would raise another issue about families. If they have to visit a loved one 50 km or 100 km from home, just imagine the cost involved. Members in the Chamber— any of us could be in this situation—can afford to visit a loved one, but many people cannot do so. That is another reason why the situation is intolerable.
Kevin Foster
It is very interesting to hear the right hon. Gentleman’s statistics on my own area of Devon. It is important to get to grips with the issue for the reasons he has mentioned. He raised the point about communications in the example of the expensive round trip from Devon to Maidenhead. In many cases, families may know where their loved one will go, but the reality is they are presented with a choice: “Your loved one needs treatment—this is where it’s going to be. There is not much you can do, other than trying to mitigate all the impacts in the best way you can.”
Norman Lamb
Such a situation leaves the family feeling desperate, guilty that they can do nothing to help their child or loved one, and powerless to do anything. That is similar to the case of Josh Wills, a little boy with autism, who lives in Cornwall. He was placed in a specialist unit in Birmingham, so we can imagine the journey his parents had to make every week. He was there for more than three years, and when I was the Minister, I had to intervene personally to get the commissioners to London to try to sort out the case. Josh is now back in Cornwall, but it took far too long for that to happen. Such cases must put families under intolerable pressure and strain.
I should mention the areas where the problem is at its worst. In the Lancashire Care NHS Foundation Trust, there were 30 cases in August. Again, that is one a day. In the Kent and Medway NHS and Social Care Partnership Trust the figure was 30, in West London Mental Health NHS Trust it was 25 and in Birmingham and Solihull Mental Health NHS Foundation Trust it was 25. Again, there is the caveat that we do not know where the responsibility lies, but we should all accept that the practice is not acceptable and has to be brought to an end.
The data focus on non-specialist beds. There will be cases, just as with physical health problems, where a patient needs specialist input and where a referral to a specialist hospital, such as Papworth in the case of a heart condition, is appropriate. However, non-specialist beds and services should surely be provided closer to home. So we got these data together and they now allow us to hold the system to account. As well as establishing the dataset, we got Monitor and the Trust Development Authority to do, to use the jargon, deep dives into a number of organisations, both good organisations and those with a bad record of out-of-area placements, to get a better understanding of what was going on. When they reported back to me, their conclusion was that this problem ought to be solvable.
That is the important point for the Minister. It is not that this problem is something we would all love to solve but find it impossible to do. It is achievable, but it requires drive, ambition and determination to see it through. If I may, as an ex-Minister, I will offer a bit of advice to the incumbent. It is no good saying that we need to make incremental progress to reduce the numbers. We need to establish the principle that this practice is not acceptable. Someone in a mental health crisis who does not require specialist care should not be sent away from home, full stop. This is not a difficult issue. It should become what in the NHS is known as a “never event”—it should never happen. If we know that there is a link between this practice and an increased risk of suicide, how can we tolerate it?
The Minister has to set the objective of ending this practice. I understand that it will take time. Back in March, I wanted to see it end by the end of this calendar year. I recognise that that is now not achievable, but I set the objective of ending it within 12 months. That is achievable, provided that there is drive, ambition and purpose to make it happen.
A related issue is that of money. I have made it clear that I totally sign up to the importance of doing things differently and making better use of resources to achieve good results for people. However, investment is needed in mental health. In the negotiations in the run-up to the March Budget, my right hon. Friend the Member for Sheffield, Hallam (Mr Clegg) secured £1.25 billion of extra investment in children and young people’s mental health services for the five-year period of this Parliament. In year 1, the amount that ought to have arrived on an equitable division of that £1.25 billion was £250 million. The amount that was made available was £143 million, which means there is a shortfall.
We were told that that was because we were part way through the year, we had had the general election and we needed to make sure that the money was spent effectively. I sort of accepted that explanation, but I have since heard from reliable sources that there was a land grab going on and that money was taken away from children and young people’s mental health services to prop up the finances of acute hospitals, for example. I urge the Government to make good the shortfall in future years.
On 13 October, the Minister helpfully reconfirmed that the full £1.25 billion would be spent in this Parliament. I call on him to repeat that commitment today. It is critical that the extra investment that was confirmed in the Budget in March is stuck to. It is a matter of good faith by the Government and I would like to hear that confirmation. I also think, incidentally, that we should make good the shortfall in year 2 because, just as with the rest of the NHS, frontloading the money to invest in change is the best way to use the resources that are available.
I will move towards the end of my contribution, which has been rather elongated owing to the additional time that is available. I will end by asking specific questions of the Minister. I would be grateful if he addressed each of them directly this afternoon. If he is unable answer any of those questions directly, I would be grateful if he wrote to me as soon as possible and responded to them directly.
First is the issue of principle. Does the Minister accept that this practice is intolerable? I am not talking about specialist beds; I am talking about non-specialist beds where someone at a moment of mental health crisis, or in other circumstances, is shunted around the country—a practice that would never be tolerated in physical health. Secondly, will he commit to ending that practice completely within 12 months, and effectively to make it a “never event”? Thirdly, will he personally drive that change, because I know from experience that that is necessary? He needs to be on the case constantly to ensure that the system responds to that moral imperative.
Fourthly, will he ensure that all providers provide the data that their contracts oblige them to provide to the information centre? Anything short of that is completely unacceptable. The data are still in experimental form, and information centre notes state that they provide a “reference point” for a more accurate measurement in the future. There must therefore be an evolution to get to a point where data around the country are completely accurate, so that providers and commissioners can be held to account. Will the Minister commit to ensuring that the experimental data are turned into final-form data that we can all rely on?
Finally, will the Minister reconfirm his total and absolute commitment to ensuring that £1.25 billion of additional investment is spent on children and young people’s mental health services this Parliament? Will he commit to sticking with the vision that we published in October last year and to introduce comprehensive maximum waiting time standards? I did that work—which led to the publication of that document—in collaboration with the Secretary of State, and he was incredibly helpful in supporting me to get that published. The vision was clear, and it recognised that until we have comprehensive waiting time standards for mental health, just as exist for physical health, we will not get equality of access to treatment. An essential principle in a publicly funded service is that all people must have the same right to receive evidence-based treatment on a timely basis. As I have said, will the Minister write to confirm any specific point that he feels unable to deal with this afternoon?
The Minister for Community and Social Care (Alistair Burt)
We have been fortunate in having rather longer than we normally get for an Adjournment debate, and that has allowed the right hon. Gentleman to speak at greater length about some of the issues affecting the historical imbalance between mental and physical health, with particular emphasis on out-of-area mental health placements. I congratulate him on securing this debate, and I am delighted to respond to it.
I thank other hon. Members who have contributed to this debate, including the hon. Member for Ceredigion (Mr Williams), the right hon. Member for Carshalton and Wallington (Tom Brake), and my hon. Friends the Members for Torbay (Kevin Foster), and for North West Norfolk (Mr Bellingham). My hon. Friend the Member for Halesowen and Rowley Regis (James Morris), who chairs the all-party group on mental health, has dropped in as part of his responsibilities in the House, which I welcome. I also welcome the Whip, my hon. Friend the Member for Truro and Falmouth (Sarah Newton).
Before I come on to respond in more detail, let me make one or two general remarks. The right hon. Gentleman referred right at the beginning to the long-standing nature of some of these problems. These issues have not arisen in the past six months. They have been here—Government in, Government out—for some time. The coalition Government made huge strides in recognising the importance of mental health and drove forward some of the changes that needed to be made. It is certainly clear that part of my responsibilities now is to pick up on that and to build on it.
If I may just make reference to the right hon. Gentleman for a moment, I think his key achievements include: the expansion of psychological therapies; the reduction in the use of police cells for people experiencing a mental health crisis; introducing the first access and waiting time standards; and piloting the sense that there has to be parity of esteem. Those achievements absolutely underpinned what I came in to find in the Department. The intractable nature—or at least intractable up to now—of some of the problems has been graphically illustrated by the right hon. Gentleman’s passionate expression today of some of the things he was not able to do during his time as Minister. They set the baseline for what I hope to do. He asked for a personal commitment to drive forward the changes. Absolutely. The bar has been set quite high.
As the right hon. Gentleman and others have mentioned, what has puzzled me most since being in office is the variability of practice. How is it that in two areas side by side with exactly the same resources there will be one that has a set of procedures in place to ensure that good treatment is provided, while in another that is not the case? It is not always about resources, but management and leadership. I have been puzzled by why there is so much variability.
There is another puzzle that is very pertinent to what we are talking about today and to which the right hon. Gentleman referred: the perverse incentives in the system. Treatment costs are split between local authorities and the NHS. They seem to be based not on what is in the best interests of the patient, but on what suits the budget best. Now, none of us are naive. We all know this goes on. However, his description of the letter from his constituent, which I know about because I responded to him about it this week, illustrates the impact on the individual of decisions that people make for perverse incentive reasons—perhaps relating to budget, if that was one of the reasons. I am interested, as he is, in why there is such variability between areas. Some areas seem to have very few out-of-area places and others do not.
I hope to be able to deal with all the right hon. Gentleman’s questions, but before I do I want to put a few points on the record. The Government’s commitment is clear. We have given the NHS more money than ever before for mental health, with an increase to £11.7 billion last year. We have made it clear that local NHS services must follow our lead by increasing the amount they spend on mental health and making sure beds are always available. In the spending review and autumn statement, we announced an additional £600 million for mental health over the next five years to increase psychological therapies, crisis care and perinatal mental health. This reaffirms our commitment to achieving parity of esteem for mental and physical health.
In perinatal mental health services, for example, I want to ensure that women are able to access the right care at the right time, and close to home. I know that provision of specialist perinatal mental health services varies across the country. Some women have access to excellent care and support, while there are serious gaps in provision in other areas. Women suffering the most severe and complex perinatal mental illnesses need access to specialist in-patient mother and baby units, and good quality community support care in the area where they live. There are currently 15 units in England—I understand that the number fell by a couple from between 2010 and 2015—but NICE estimates there is a UK shortfall of between 60 to 80 mother and baby unit beds. That is why we announced in the March Budget that the Government would invest an additional £75 million over the next five years, £15 million a year, to support women suffering from mental ill health in the perinatal period. NHS England is leading a work programme to ensure that this extra money is spent in the right way at the right time and in the right places. The right hon. Gentleman’s work has made that base. I give him as much assurance as I can that in the areas where he set the work in progress, that work is going to continue; in places where the work is going slowly, it will be challenged; and in places where he was not able to make the progress he wanted to make, I set myself the challenge to do just that. I do not have to worry an awful lot about freedom of information requests because I will get the questions from him and from a number of hon. Friends and colleagues who have grasped how important this issue is.
Let me return to the source of the debate. I greatly appreciate the work that the right hon. Gentleman put in train earlier in the year with NHS England and mental health provider organisations to understand the pressures that lead to people being sent away from home for treatment that should be available locally. This has helped to provide a picture of the scale of the problem and to raise its profile. We know that the principle should always be for care close to home in the least restrictive setting. It is not acceptable for people to be travelling for miles when they are acutely unwell.
I know about the case that the right hon. Gentleman raised because I dealt with it this week, and I agree with him that some of the attitudes expressed by some of those responsible for people’s care are just not good enough. It cannot be acceptable and it cannot have been acceptable to listen too little to those who are in care or who are being cared for when they have made complaints about treatment. I am well aware of the problem—I am occasionally chased on Twitter about it—and I say to one or two of the groups that I am looking carefully at how to deal with it better. Sometimes people feel that they have not been listened to, and I suspect that the sort of example revealed in the right hon. Gentleman’s constituent’s letter might be rather more common than we think. Accordingly, I want to ensure that the inspection and regulation regime really picks things up. I know that there will sometimes be differences in opinion and that things will need to be clarified, but I do worry about the attitudes sometimes expressed, and I want to make sure that the Department has really got hold of ensuring that those sort of complaints are picked up and, whenever possible, really burrowed into to find out what might have gone on.
Norman Lamb
I appreciate the Minister’s reassurance. One of the issues highlighted in my constituent’s case was the fact that he was transported very late at night, arriving at about 1 am, and there was another person from Norfolk in the same unit that same week who was collected at 1 am from the unit to be brought back to Norfolk. This treats people like chattel; it does not treat them as human beings. Is the Minister prepared to highlight to the Care Quality Commission that it should investigate and explore that particular aspect—the transporting of people—because having to travel in a minibus with someone who does not talk to them for three hours, and arriving very late at night is simply outrageous?
Alistair Burt
Of course it is, and I share the right hon. Gentleman’s frustration. I write a lot of letters to colleagues who express concerns and I have to signpost them to the other organisations in the health sector that have responsibility for taking particular decisions. That is quite right, because local decisions ought to be local. Clinical commissioning groups or trusts need to be responsible and accountable for what they are doing. However, I have to tell the right hon. Gentleman that it is occasionally frustrating when I feel that I cannot pick up the phone and make my own inquiry. We cannot run a system in which Ministers arbitrarily pick up cases because they are the ones we know about; there has to be a structured system. When particular things come to light, I am looking at how to use my position and the authority of the Department to make sure that something has been properly gone into—even if it is somebody else’s statutory responsibility. We in this House who remain accountable for things should be able to make sure that those statutory groups, including the CCGs, have really got a grip. I am keen to pursue that.
Mr Bellingham
Does the Minister agree that there is something fundamentally unsatisfactory—and, indeed, wrong—about moving someone late at night unless it is absolutely necessary for medical and clinical reasons?
Alistair Burt
Yes. It seems very puzzling that that should be a regular practice, if it is. That should not be the case. Of course there are all sorts of different pressures on the system, and it would probably not be appropriate to say that it should never happen, but, in principle, people who are in a state of anxiety should be moved with the maximum care, at the time that is of greatest benefit to them and their health needs.
As I was saying, it is not acceptable for people to be travelling for miles when they are acutely unwell. It is also not acceptable for staff to be spending time phoning around to find beds for their patients.
Let me return briefly to the impact of social media. A couple of weeks ago, I read in a tweet from a frustrated doctor—I hope he will pick up on today’s debate—that on that particular day no bed had been available for a woman anywhere in England. Along with the hon. Member for Liverpool, Wavertree (Luciana Berger), who had raised the matter with me, I made inquiries and found that that was not technically true; beds were available. The response from the doctor was, “You may be technically correct, Minister, but it is very difficult to find them”, and the results of my inquiries suggest that that is true. We need to establish a better system of identifying beds that may be available, because that too is part of the problem. People should not be spending time looking for beds. I have an idea about that, which I shall mention later in my speech.
I had to tell the clinician that I did not think that, technically, what he had said was true. However, I recognise that for those who are in the business of finding beds for people, it should not be as difficult as it appears to be, and I want to establish what we can do to help.
We know that the need to place people out of area, away from home, family, friends and networks, is a “warning sign” of a mental health system that is under pressure, and we know that no one wants to spend scarce resources on sending people out of area. However, we cannot look at out-of-area treatments in isolation, because they are part of the mental health acute care pathway as a whole. I welcome the interim report of Nigel Crisp’s commission, which was set up to review the provision of acute in-patient psychiatric care for adults, and I look forward to reading his final report and recommendations early in the new year.
Lord Crisp’s interim report made it clear that—as I am sure the right hon. Member for North Norfolk knows—the situation is more complex than a shortage of beds. We know that there has been a long-term reduction in the number of psychiatric beds in England, but the report suggests that in many areas there would be enough beds if improvements were made to other parts of the system and integrated, community-based services were commissioned. That very point has been made this afternoon in relation to the variability of practice. The report also made it clear that the so-called bed crisis, or admissions crisis, is a problem of discharges and alternatives to admission, and can be dealt with only through changes in services and in the management of the whole system.
As the right hon. Gentleman pointed out, that can be done, as has been demonstrated in a number of local areas. Sheffield, for example, has almost entirely eliminated adult acute out-of-area treatments, and has reduced average bed occupancy to 75% by redesigning the local system, That has included investing in intensive community treatment, and working in partnership with housing. In the right hon. Gentleman’s own constituency, Norfolk and Suffolk NHS Foundation Trust has begun to reduce its historical problem of out-of-area treatments through a combination of investing in more acute adult beds and working with commissioners to develop community and crisis resolution services.
I understand that the independent Mental Health Taskforce has spent some time discussing these issues. I hope that its report, which will be published in the new year, will be an important driver for improving mental health services over the next five years, and will address many of the key issues raised in Lord Crisp’s interim report.
Norman Lamb
Can the Minister confirm the likely publication date of the taskforce’s report? I think he said it would be in the new year, but can he give me his best estimate of a specific date? Also, I would like to acknowledge that the Norfolk and Suffolk NHS Foundation Trust has made real progress. The number of people being sent out of area has come down significantly, and that needs to be recognised.
Alistair Burt
I am grateful for the right hon. Gentleman’s comment about his trust. My understanding is that the taskforce’s report will come through very shortly. I am not sure whether it will be done this month or by the start of next month, but it is imminent.
I appreciated the right hon. Gentleman’s kind remarks about the Secretary of State for Health. The Secretary of State has already agreed an action plan to tackle out-of-area treatments for adult acute in-patient care. Where out-of-area treatments are a problem, local areas will be asked to put in place clear action plans demonstrating how they can reduce out-of-area treatments, in the best interests of patients, during the course of 2016-17. Now I come to one of the right hon. Gentleman’s challenges. Building on this, I intend to go further and put in place a national ambition to address out-of-area treatments. I will do this in consideration of the Crisp commission and the taskforce report, and I will communicate details of this ambition by the end of March 2016—that is, by the start of the next financial year.
I want to wait and see what Lord Crisp and the Mental Health Taskforce say and then consider exactly what the ambition should be. Should it be an ambition for complete elimination? Should it provide a much tighter variation? I want to see those reports before I set the ambition, but I will set it, and the targets, and come back to the right hon. Gentleman and the House before the end of March next year to communicate those decisions. I hope that helps.
I also commend the right hon. Gentleman for recognising the need to improve mental health crisis care and for launching the mental health crisis care concordat, which we have discussed today. This debate has given us an opportunity to talk about variation in practice, the quality of street triage and the fact that we can do different things in different areas. I saw the work being done in Bradford, for example, where the mental health practitioner is located in the control room, as opposed to being on the street. The galvanising of local groups to work together by giving them the responsibility of doing the job has been absolutely vital. The way in which we are reducing the number of people detained in police cells is a clear example of how that process is working.
The Government are equally committed to reducing out-of-area mental health treatment for children and young people. In-patient child and adolescent mental health services—CAMHS—admission is a relative rare event. At any one time, however, there are approximately 1,300 children and young people from England in CAMHS in-patient services. Services themselves are usually subdivided into different specialties, such as eating disorder units or low secure units. That means that it is highly challenging to provide complex care in all areas, and on occasion, some children and young people may need to be referred for specialist treatment at a distance from their home, if that is in the best interests of their care. However, we are committed to ensuring that that is as rare an event as possible, and much progress has already been made.
Norman Lamb
One of the recommendations from the taskforce that NHS England established to look at tier 4 services, at the number of beds required across the system and at the variability of the services was that treatment should always be contained within a region —in other words, that no child who lives in the south-west should ever go out of the south-west for treatment. I cannot remember where the child from Torbay had to go—
Norman Lamb
Indeed. Is the Minister going to stick to that? Is he going to ensure that that is the objective, and will he monitor it to ensure that he meets it?
Alistair Burt
As much as possible, absolutely, yes. There will be occasions when very specialised treatment has to be given, and that will on occasion be outside the area. But apart from that, absolutely. We want to provide care that is appropriate to people in a place that is closest to where they are, as much as possible.
In 2014, NHS England published the tier 4 CAMHS review. This found a relative shortages of beds in some regions, meaning that some children and young people had to travel long distances to access a bed, owing to an uneven distribution around the country. As the right hon. Gentleman knows, there was an immediate response to this: £7 million in additional funding, taking the total number of beds now to 1,440, the highest number there has ever been. In addition, NHS England has introduced new national protocols for referrals and discharge, and a new “live” bed monitoring system to make the best use of existing capacity. I am interested in whether that capacity has reference and relevance to the adult acute beds, and could it make the job of my friend the clinician doctor that bit easier?
But while these measures have helped in the short term, we want to build on this progress still further and ensure long-term, sustainable improvements. In January this year, NHS England commenced a comprehensive review of the procurement and commissioning of inpatient beds. The aim of this is to establish the long-term requirements for inpatient services and ensure quality, sustainable services are commissioned in the right place, based on population need.
It is not enough simply to provide more and more beds. In order to ensure that improvements are sustainable, we need to improve the community-based support we offer to children and young people. This is at the heart of the vision set out in “Future in mind”, and we are determined children and young people have easy access to the right support, from the right service, at the right time and as close to home as possible.
Key to achieving this vision are the local area transformation plans now being put in place. CCGs have been asked to work with NHS specialist commissioning teams responsible for inpatient services in the creation of these plans.
I have two final points. I have been interested in what data are available and what are not, and I answer a number of questions by saying, “The data for these are not collected centrally.” I am looking hard at each and every one of those questions, asking, “Are there occasions when we should be doing more on the data?” There is a lot still to do, but I entirely take the right hon. Gentleman’s point.
On data, we are looking at the limitations. The right hon. Gentleman was right to talk about the problems in getting this dataset right, but, again, I am on to that; it is essential, and I will take the challenge of driving and moving on that data.
On providers, the responsibility seems to come down to CCGs. It is unacceptable that private providers do not submit data. Some more have started submitting since the summer. It is the responsibility of CCGs, who have the contractual levers, and need to use them. That is not good enough; if we need this information, we need this information. I am going to look at whether the CCGs are using those contractual levers, and if not, why not. If they are not, and a sanction can be applied, we will apply the sanction. That information is necessary, and I am going to do this. The right hon. Gentleman is absolutely right on that.
On the principle in respect of determination, I will come back to the right hon. Gentleman by March next year and set out the national ambition. Do I commit to ending the practice completely? I do not know yet, because I want to get the result of the commission. It is right that it should be reduced to an absolute minimum. I want to know technically whether it is possible to eliminate it, or whether that would actually not do the job that is necessary. I want to see what the commission has to say.
Will I drive these changes? Yes, I will. Will all providers provide data? Yes, they will. Will I commit to the £1.25 billion? Yes, I will. I have said that enough times in enough places to make this a very difficult Government commitment to slip away from. It is over the course of the next five years, but I am happy to repeat that.
Norman Lamb
I am grateful to the Minister for his patience in allowing me to intervene again. I am conscious that there is a risk that the shortfall in the first year is made up in 2020 or something like that. Because of the principle of frontloading to invest in change, it would be incredibly helpful if we could get the commitment to make good the shortfall in 2016-17. Can he commit to doing that?
Alistair Burt
There are things I can do and things it is unwise to take a flyer on, standing at the Dispatch Box.
Alistair Burt
I will try, but we need to make sure all the money is used sensibly. There are a lot of pressures on the system, and I am trying to be as bold as I can without being foolishly bold and saying things just for the sake of it. I understand the importance of this £1.25 billion. I have spoken about it a great deal; I want to see it all used. I am not responsible entirely for the timescale, but I understand the right hon. Gentleman’s point and I suspect it will come up in the Opposition day debate we have next year.
I will talk to the Secretary of State about the right hon. Gentleman’s last point about comprehensive maximum waiting times. I will see where we can go further and include it in a comprehensive letter to the right hon. Gentleman.
I hope that this has been helpful. I am delighted that we had extra time to cover the ground. I am pleased to take up the challenge to do some of the things that could not be done in the past few years, and I will do my best to live up to the expectations of the House, as expressed by a number of Members today.
Question put and agreed to.