Mental Health: Ensuring Equal Access to Mental and Physical Healthcare
(8 years, 6 months ago)
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Baroness Brinton
That this House takes note of the recommendations of the Five Year Forward Review for Mental Health and the case for ensuring equal access to mental and physical healthcare.
Baroness Brinton (LD)
My Lords, I am grateful to have this debate on the importance of mental health and look forward to hearing contributions from your Lordships.
Although attitudes are changing, some people still think that mental illness does not affect them or us, but it does. One in four of us will have a mental illness at some time in our lives. We will all have someone close to us who has experience of mental health issues—I know I have—but there is also a wider cost to society. The cost of mental illness to the economy is estimated at £105 billion a year and the employment rate of people with severe and enduring mental health problems stands at just 7%. The effect on our National Health Service is substantial, too. People with mental health illness have over three times more A&E attendances than those without, and are five times more likely to be admitted to acute service hospitals. Of particular importance is the fact that more than one-third of GP consultations are related to mental health. Nine out of every 10 people who either attempt or die by suicide already have a record of suffering from mental illness.
Between 2011 and 2014, there was a 33% rise in the number of mental health-related incidents dealt with by the police and a worrying increase in people with mental illness being held in police cells due to lack of appropriate NHS bed provision. Last November, it was reported that a 16 year-old girl was held in a secure police cell for 48 hours in Torbay because there was no acute mental health bed anywhere to be found. Imagine if that were your underage daughter, niece or granddaughter in severe distress, having committed no crime, in an alien criminal justice environment. But there was also a consequence for the acute hospital, as a nurse had to be with her the entire time, costing the hospital substantially more than the provision of an emergency bed. Sadly, this is not an isolated incident and inquest after inquest asks for action, but until there are effective weekend crisis services I fear that nothing will change.
The independent Mental Health Task Force Report, The Five Year Forward View for Mental Health, published this February, sets out the crisis in our mental health provision and makes many recommendations. The task force, chaired by Paul Farmer, also points out that this goes way beyond NHS provision. People with mental health problems need,
“to have a decent place to live, a job or good quality relationships in their local communities”,
and the wider inequalities of mental illness must also be tackled. Mental health problems affect disproportionately those living in poverty as well as black, Asian and minority ethnic people, and their involvement in the criminal justice system before they get access to health support and treatment is shocking and a shameful reflection on our society.
The report makes many recommendations but for Liberal Democrats there are some important core themes which we also had in our manifesto last year, and these remain key priorities for us. First, there needs to be comprehensive access to waiting times and standards in mental health, giving people the right to treatment in exactly the same way as for those with physical conditions. In coalition government, the Liberal Democrats introduced the first ever maximum waiting times in mental health for conditions such as depression, anxiety and psychosis. This was the first part of a vision for comprehensive waiting-time standards, championed in government by Norman Lamb MP, then Minister for mental health, who has continued his fight for these standards ever since.
Secondly, there must be 24-hour access to mental health crisis care seven days a week and this must be funded properly so that crisis resolution teams and home treatment teams can offer a real alternative to hospital admission, which is both better for the patient and, in the long run, cheaper for the NHS. The task force acknowledged the crisis care concordat joint agreement in February 2014, which describes how police, mental health services, social work services and ambulance professionals should work together to help people going through a mental health crisis.
Behind every strategy and behind the statistics there are personal tragedies. In April this year an inquest heard how 17 year-old John Partridge, a talented young musician, was allowed to discharge himself from Derriford Hospital in Plymouth because the inexperienced junior doctor had no mental health consultant to turn to for advice, and crisis mental health services for 16 to 18 year-olds were not available over the weekend. Despite his history of self-harm and attempted suicide, he was not even assessed in person. He was treated as an adult and permitted to discharge himself.
I believe that, as in physical health, there should be “never events” in mental health. In physical health the list includes operating on the wrong limb or leaving a foreign object in a patient after surgery. There is one current mental health never event, and it is important: the failure to install functional collapsible shower or curtain rails. However, the definition of mental health never events must surely be extended so that someone with a history of self-harm and attempted suicide must be seen and supported and not discharged until a senior psychiatric clinician is confident that it is the right thing to do. I hope the Minister can confirm that the “never” list will be expanded to include suicide risk immediately after leaving mental health care.
Thirdly, the practice of sending acutely ill patients long distances for treatment should be stopped as quickly as possible. In February this year it was estimated that 500 patients a month were being taken more than 30 miles, and some more than 100 miles, to the nearest available bed. Norman Lamb, my noble friends Lady Tyler and Lady Walmsley, I and many others have also made repeated requests for this practice to end. The noble Lord, Lord Crisp, who led the Commission on Acute Adult Psychiatric Care, found that there are major problems both in admission to psychiatric wards and in providing alternative care and treatment in the community. One of the commission’s key recommendations is that the practice of sending acutely ill patients long distances for non-specialist mental health treatment should be phased out by October 2017. Can the Minister confirm that the Government and the NHS will be accepting this recommendation in full and that the practice will indeed end by October next year?
I ask the Minister to update your Lordships’ House on the progress of the five-year forward view task force implementation plan. Time and funds are running out and I know that many providers are keen to hear the Government’s view. The Government’s commitment to an extra £1 billion to meet the report’s recommendations after the launch is welcome but this will not be enough to deliver the report’s recommendations. Even more worrying, it seems that the funding may come from the additional £8 billion the Government have already pledged to deliver the general five-year plan, meaning that mental health will not receive any more than it would have got on the basis of its historical and deeply inadequate share of resources—about 13% of the total NHS budget, despite accounting for around a quarter of the national burden of disease. A figure of 13% is neither parity of esteem nor parity of resource.
Worse, the report Funding Mental Health at Local Level: Unpicking the Variation, published by NHS Providers a week ago, raised serious concerns that the necessary investment is not reaching many local areas and services. This is despite recent funding commitments such as the £1.25 billion five-year CAMHS investment announced by the coalition Government in the March 2015 Budget. The report says that, “Only half”—just over half—
“of providers reported that they had received a real terms increase in funding of their services in 2015/16”.
In addition:
“Only a quarter … of providers were confident that their commissioners were going to increase the value of their contracts for 2016/17”.
There is also confusion over,
“what it means to implement parity of esteem”,
including,
“confusion over what services should be covered, and how much investment should be made”.
Furthermore:
“Over 90% of providers and 60% of commissioners were not confident that the £1 billion additional investment recommended by the mental health taskforce”—
for CAMHS—
“will be sufficient to meet the challenges faced by … services”.
At the heart of the problem is the inclusion of additional funding in the commissioner’s baseline allocations. The many competing claims on the additional money given to commissioners makes it more challenging to ensure that the funds are not diverted to other priorities but are used for the intended purpose of delivering much-needed improvements to mental health services.
These findings support a previous analysis by the BBC, which found that the £143 million investment in CAMHS was not reaching front-line services. The Mental Health Network expressed suspicions that the funding was being diverted to other services. CCGs and mental health providers have expressed support for the ring-fencing of additional resources for mental health. Some mechanism is required to ensure that funding gets through. Can the Minister inform the House which financial resources will be provided for mental health services and what guarantees there are that this funding will be ring-fenced, reach front-line services and be transparent and accountable?
One in 10 children between the ages of five and 16 suffers from a diagnosable mental health condition, and there is now substantial evidence to show that three-quarters of mental health problems start before the age of 18. It is, therefore, an absolute moral and economic responsibility for us to ensure that children and young people get the help they need as soon as possible, and in the right place and at the right time.
The Future in Mind: Promoting, Protecting and Improving our Children and Young People’s Mental Health report, launched a year ago last March, made some very clear recommendations about commissioning and improving access, about mental health support in schools and especially about ensuring that those from vulnerable and hard-to-reach backgrounds, including looked-after children, get urgent and bespoke help.
There are numerous stories about very long waiting times for referrals to CAMHS and considerable variance in different areas. The average waiting time in Gateshead is five times as long as that on Tyneside, just down the road. Some areas have referral rules that children must have “enduring suicidal ideation”—that is, they must have expressed suicidal thoughts on multiple occasions—before they are able to be seen. This is unacceptable. Children and young people need support much earlier.
In 2014, the Department for Education published statutory guidance to schools on supporting pupils with medical conditions. The guidance says:
“In addition to the educational impacts, there are social and emotional implications associated with medical conditions. Children may be self-conscious about their condition and some may be bullied or develop emotional disorders such as anxiety or depression around their medical condition”.
However, schools wanting to help their pupils who may be exhibiting mental health problems have their hands tied behind their back. Despite the continuing increase in the number of pupils across the country, the number of school nurses is reducing. Many schools see their school nurse only briefly—once a week or, worse, once a fortnight—so there cannot be effective dialogue between school nurse and staff, let alone school nurse and pupils. These cuts are continuing, especially with the cuts in public health budgets.
What are the Government doing to ensure that school nurse places are being protected? What dialogue exists between the Department of Health and the Department for Education to ensure that the vital role of schools in identifying the need for early intervention can happen?
That brings us back full-circle to the start of my contribution. First and foremost, resolving the crisis in mental health is a funding issue. Do the Government understand that all the good work done by the Mental Health Taskforce and others in identifying the problems and making recommendations to solve them will come to naught without a real-terms funding increase? Shifting money around will not do the job. Secondly, we will only solve the issues by real cross-departmental working.
What plans are there for true parity of esteem and a real cash injection into mental health services in both this year and the remainder of this Parliament? What cross-departmental working is happening at the moment? Without it, we will continue to hear of personal tragedies—lives wasted or ruined because our current mental health services are completely inadequately funded.
Lord Oates (LD)
My Lords, I welcome the opportunity to take part in this important debate on the Five Year Forward View for Mental Health initiated by my noble friend Lady Brinton. As my noble friend said, mental health is a topic which touches almost everyone in this country, whether through direct personal experience or through families and friends who have suffered from mental ill-health.
For much of the time when I was growing up, it was pretty much a taboo subject. Few people talked openly about mental illness; it was too often a personal burden not to be shared, understood or tackled but to be hidden away even from those closest to one. In recent years there has been a welcome shift in our attitudes, and I pay tribute to the mental health charities and the many activists and campaigners, such as Alastair Campbell, who have helped break down taboos and get mental health on the agenda, but I also pay a real and heartfelt tribute to Norman Lamb in particular who, as a Health Minister in the previous Government, strongly supported by the then Deputy Prime Minister, Nick Clegg, did so much to push the issue of mental health right up the government agenda, placing mental health literally on the front page of the Liberal Democrat manifesto.
I am pleased that the subsequent Conservative Government have reiterated their commitment to tackling the huge inadequacies that exist in mental health care today and which are highlighted in the report we are discussing, but I hope that they will commit themselves to willing the means as well as the ends. Warm words will not be enough when mental health provision remains severely under-resourced and where we need real will to ensure that the services and support that can help prevent mental illness are there and joined up.
Mental ill-health is something I have experience of both personally and through supporting people whom I care for very much who themselves suffered with mental health problems. In my teenage years and my early 20s, I suffered severely with depression and suicidal thoughts. For much of that time, I would go to sleep praying that I would not wake up in the morning, so I would not have to bear any more of the paralysing burden of despair that I felt. It is difficult to describe quite how terrifying it is to be caught in a spiral of depression, how it impacts on your physical health, how it drains all the energy from you. Back then, in the 1980s, you did not generally discuss such things: you bottled it up inside and tried to show a cheerful face to the world. I was lucky because, although I never articulated my despair directly to anyone, I had a supportive and loving family and some of the most amazing friends whose support at the bleakest moment for me saved my life and made living a better prospect than dying. Tragically, as the review sets out, that was not the case for thousands of people last year. Suicide is now the leading cause of death for men aged 15 to 49. What a terrible and tragic waste.
As we know, a wide variety of factors can lead people into mental ill-health. Adolescence in itself is a pretty confusing and difficult experience for most people. For me, it was compounded by trying to come to terms with issues about my sexuality—something I was desperately trying to hide from myself, let alone from anyone else. It was not a great time to be an adolescent coming to terms with being gay because, throughout the 1980s, the drumbeat of homophobia was beating steadily louder, culminating, just as I turned 18, in the passage of the infamous Section 28 of the Local Government Act 1988—the Government of my own country legislating in prejudice against people like me.
Almost a quarter of a century later, I was fortunate to be working in the coalition Government when, at the instigation of my noble friend Lady Featherstone, the coalition legislated for full equality via the equal marriage Act. Nick Clegg reported at the time a conversation that he had with a wonderful mutual friend who, on passing Moss Bros and seeing two grooms in the window, told Nick, “I literally felt myself walk a little taller”.
I make that diversion into that area because I think that we should all recognise that the actions of government, churches and other institutions can have profound impacts on the self-worth and mental health of individuals. I hope that organisations of all faiths, particularly the Anglican Church, of which I am a member, think about that a lot more and show the sort of leadership that it once showed in the days of Archbishop Ramsey.
I was lucky enough to come through my struggle with mental illness with the love and support of friends and family, but many people do not have the support networks that I was lucky enough to have. Too often, as the review sets out, the services that people need are not available. Just half of community mental health teams offer 24/7 crisis care. Only a minority of A&E units have 24/7 cover from mental health liaison teams. As my noble friend Lady Brinton pointed out, too many black and ethnic minority citizens access mental health care first through direct contact with the police. Care for people with eating disorders remains haphazard and often entirely inadequate, and services for young people are unco-ordinated and do not provide anything like what is required.
Over recent years, I have seen the inadequacies of service provision at close hand, in two areas—first, in the services available to those suffering from serious eating disorders, where provision can vary massively across the country and, in many cases, is so inadequate. In the experience I was aware of, there was adequate provision only because the family had the money to buy private provision. The second area is provision for adolescents suffering acute mental health problems. Many areas seem unable to have a properly joined-up approach between schools and mental teams. Children are often no longer in school because of their mental health problems. At the most basic level, there is a lack of provision for those children to continue their education, and if they fall out of education at that point, it can cause more serious problems and compound existing mental health problems.
The provision of services to help young people—in particular, talking therapies—is utterly inadequate, which can have tragic consequences. It is hard to convey the distress and anguish of parents and other family members when they are unable to gain access to services for young people struggling with terrible mental health problems. The adequate provision of mental health services requires much more effective joining up of services, but it also requires extra resources, as the review states. Yesterday, in the debate on the Queen’s Speech, the Minister, the noble Lord, Lord O’Neill, said that the Government are building our economy on low taxes. I am all for lower taxes, particularly for those on the lowest incomes—I was proud of the work of the Liberal Democrats in government in raising the personal allowance—but the taxes we raise and the taxes we levy must be sufficient to provide the services that we require in a civilised society. We have to decide what those services are and then work out how we pay for them, not the other way round. I hope that in his reply the Minister will confirm that the Government will provide the extra resources that the report identified as being required and that, as my noble friend Lady Brinton said, they are additional resources, not an accounting fix.
I hope the Minister will also commit the Government to making a reality of the commitment to provide equality of treatment for mental and physical health. To do that will mean the Government putting a huge amount of energy into this issue. It is so complex and there are so many issues to resolve that they have to champion and drive it the way that our friend Norman Lamb did in the previous Government. If the Government fail to do so, their failure will not just be about never getting round to deciding where an airport will be, or something like that; it will be much more material because it will be measured in millions of lives that are further blighted by the terrible suffering that mental illness can bring.
Lord Crisp (CB)
My Lords, I congratulate the noble Baroness, Lady Brinton, on her very impressive speech in which she laid out the issues extremely well. I also congratulate the noble Lord, Lord Oates, on his personal and moving speech which reminded us of what this is all about and that this affects individuals. We sometimes talk quite blandly about policies and forget that this is all about individuals.
I will start with a third congratulation, to the Government and all the political parties on having pushed this agenda so hard that we are moving towards parity of esteem between mental and physical health. I do not know whether this is the first country in the world to do that, but this is an enormous commitment with enormous implications; it is not just about access to healthcare, which the Motion in front of us is about, but about access to outcomes and a whole range of other aspects of the health system, including access to research funding and so on.
I will take a moment just to comment on the global implications. The UK has a leadership role here. Some 25% of disability globally is connected with mental illness, yet globally only 1% of health funding is spent on it. That is completely disproportionate, even more so than the figures for the UK mentioned earlier by the noble Baroness, Lady Brinton. Some changes are happening globally: there is a new World Health Organization action plan, and the sustainable development goals recognise that health needs to be thought of as a bio-psycho-social concept and not just thought of in terms of the biological health aspects. However, DfID does no better than other donors in promoting mental health, and its spend on mental health is very low. I have a question, not for the Minister but for the Government: will DfID adopt the same policy of parity of esteem between mental and physical health in its work locally?
On the UK and the five-year plan, as the noble Baroness, Lady Brinton, has already said, there is still uncertainty about what is meant in practice. I know that it is early days but there are all sorts of questions about implementation. One gets the impression from talking to people involved in mental health in England that people take very different views about what this means. As has already been said, only just over 50% of providers this year reported a real-terms increase in funding, and there is low confidence among providers that the £1 billion will find its way to mental health. I would like to hear the Minister’s comments on these points in his response to the noble Baroness, Lady Brinton.
As the Minister knows, I chaired a commission on acute care that coincided pretty much with this five-year working party and which was referred to in the five-year plan. Three issues arise from that, which I will ask about specifically. The first is that out-of-area treatments—the practice of sending people long distances across the country for admission, not for specialist care but for general acute emergencies—is a significant problem for patients, carers and the system. The latest figures suggest that this may be getting worse. In our commission we believed that this could be dealt with quite quickly, and we suggested that it could be eliminated by September 2017. We also said that in many cases it would save money to do so, because people are kept at very significant expense, often a long way away, where they get stuck because it is difficult for social workers or health workers to visit them. We therefore believed—and we saw evidence from a number of trusts around the country—that it was possible to do this quite quickly and that in many cases it was a cost-neutral option. I understand that the Government propose to set a target for achieving this by 2020, not by October 2017, as we suggested. I suspect that putting it off will mean that people will not start even thinking about this until 2018 or 2019, and it is a great pity that this is a missed opportunity to do something that is probably very symbolic as well as important as regards showing that we are serious about improving mental health.
I also predict that, in the meantime, complaints about this will grow. This will become a bigger issue and will happen more and more, and I suspect that we will have this sort of debate in your Lordships’ House more often. My first question to the Minister is: will he and the Government reconsider that timetable and move the timetable for eliminating out-of-area treatments forward? We suggested September 2017, but certainly 2020 is far too far away.
Turning from a four-year wait to a four-hour wait, our commission suggested that written into the NHS constitution—not purely as a target—should be the constitutional right for people with mental health problems to be admitted to hospital or be received by a crisis resolution and home treatment team within four hours of being assessed. At the moment that happens in some cases, but in very many cases people are kept hanging around, often in police stations and all kinds of other locations, waiting to be admitted. We believe that this is very important. We do not yet have a baseline figure for the average time that people wait for admission once it has been decided that they should be admitted. We think that work needs to be done to measure this and that there should be a commitment to deal with this waiting time. Will the Minister let us know what progress is being made on that recommendation?
My third and final question concerns a matter to which I know the Minister is very committed—ethnicity and race. For a long time there has been a problem with both real and perceived racism within mental health services. We certainly came across a large number of people from black and minority-ethnic communities who felt that they were disadvantaged or discriminated against in some way within the services. We found it very difficult to decide how to deal with this, because mental health services by themselves cannot deal with what are often societal problems. Incidentally, we also found that there was a large amount of discrimination against gay people in a number of institutions around the country.
We concluded that the way to deal with this was to introduce a race equality standard for patients and carers—such a standard is applied for staff across the whole of the NHS—as a means of measuring the differences between the treatments that people from different communities receive. We believe that that could be done relatively quickly. There are only 50 or so trusts in the country, and it would be very easy to pilot it with five or 10 of them over the next few years. I know that this is something that the department is considering and I would be very interested to hear from the Minister what is happening in this regard. We believe that showing that this issue is taken very seriously within mental health will not only be a very significant gesture but provide the sort of information that trusts need to identify the problems and plan how to deal with them.
Finally, I turn to something that was not directly mentioned in the five-year review, although there was reference to people not being given a full understanding of the side-effects of medicine. I refer to dependence on prescribed drugs. My noble friend Lord Sandwich has been a pioneer in raising the profile of this hidden and often invisible problem affecting many thousands of people, causing pain and grief, and wasting millions of pounds within the health system.
I draw particular attention to the rising levels of pharmaceutical treatments for mental health conditions. Data published in April show that anti-depressant prescription numbers rose by 7% last year to 61 million prescriptions—enough for more than one for each of us in the country, and five times the number that there were 25 years ago. There has also been a significant increase in the number of prescriptions for drugs used for psychosis, as well as for ADHD, which are usually given to children. While of course these drugs can be helpful in the short term—and that is why they are given—there is worrying evidence of an increase in long-term use of anti-depressants, as well as reports of many individuals suffering from disabling withdrawal symptoms, which can last for several years. There are also concerns that long-term use can be harmful and lead to disability.
I should therefore like to draw the attention of the House to the work of the All-Party Parliamentary Group for Prescribed Drug Dependence. Among other things, it is campaigning for a national helpline to help patients who are having problems with these drugs to come off their medication. Currently they are unable to access appropriate support. I therefore ask the Minister for his comments on the request for support for a national helpline.
Baroness Tyler of Enfield (LD)
My Lords, in my contribution to the debate on the gracious Speech last week, I said that mental health had become one of the defining challenges of our age. I am delighted that today’s debate, secured by my noble friend Lady Brinton, provides an opportunity to expand on this. We have already heard today that one in four people experiences a mental health problem in any one year, so it really is an issue that touches each and every one of us at some point in our lives. The moral arguments are overwhelming, too. As Michael Marmot so powerfully reminded us in his recent book, The Health Gap: The Challenge of an Unequal World, people with mental ill health have a life expectancy between 10 and 20 years shorter than people with no mental illness. Doing something about this is a first-order issue for social justice.
Let us look at the big picture. Demand for mental health services is rising relentlessly and will continue to do so. It has been estimated that by 2030 there will be approximately 2 million more adults in the UK with mental health problems than there are today. Mental health services must be equipped to respond to increasing and changing demand and be able to tackle unmet need—that is a huge challenge. It is undeniable that mental health is getting much more attention from politicians and policymakers, and that is a good thing. But what actual difference is that making to those one in four people? That is what I want to focus my remarks on today, as well as offering a few concrete suggestions on how we start turning all these fine words into reality.
So, what is the overall strategy for addressing this issue? In a recent exchange in your Lordships’ House at Question Time, the noble Lord, Lord Prior, was asked when the Government would be producing their strategy on mental health. The Minister replied by saying that the Mental Health Taskforce report, along with the Future in Mind report and the report from the noble Lord, Lord Crisp, on acute psychiatric care, were the strategy. Although I am quite a fan of strategy documents myself, I thought that that was quite a good answer, and so reviewed them to see if they did add up to a comprehensive strategy.
First, Future in Mind, published just before the election, was a much-needed blueprint for modernising and improving children and young people’s mental health and well-being, backed up by £1.25 billion in funding. It highlighted the fact that 75% of mental health problems start before the age of 18 but that less than 25% of young people with a diagnosable condition were accessing support and treatment. Its almost 50 recommendations for transforming services for children and young people looked right across—from preventive work and early intervention through to crisis care. It was, in my view, a very good report.
Secondly, the excellent report by the noble Lord, Lord Crisp, Old Problems, New Solutions, on improving acute psychiatric care for adults, makes a compelling case for patients with mental health problems having the same rapid access to high-quality care as patients with physical health problems. As we have heard, the report recommended a new waiting time pledge for admissions to acute psychiatric wards and the phasing out by 2017 of the practice of sending acutely ill patients far from home for non-specialist treatment. I would like to add my voice to the other voices this afternoon saying that we should not have to wait until 2020 for that to happen, not least given the expert opinion that this practice is associated with an increased risk of suicide—as we have heard so powerfully and personally this afternoon from my noble friend Lord Oates.
Finally the Mental Health Taskforce report provided a comprehensive insight into the current state of mental health care. Its verdict was striking. It says that,
“too many people have received no help at all, leading to hundreds of thousands of lives put on hold or ruined, and thousands of tragic and unnecessary deaths”.
Those are strong words indeed. With 75% of people affected by mental health issues receiving no support at all, the report makes it clear that the current mental health care system is simply not coping as a result of years of chronic neglect and underfunding. The report also made more than 50 recommendations. Priority actions were: access to mental health care 24/7 as part of a seven-day NHS, new waiting time and access standards, and expanding access to psychological therapies to help more than 600,000 people. The report also had a lot to say on a more integrated approach to mental and physical health, recognising how interconnected the two are for many people.
In my assessment, these reports taken together do give us the overarching framework needed for transforming mental health care, so I am with the Minister on that point. So, “Job done?”, noble Lords may ask. Clearly not, because after all of this very good work and three excellent reports, we are simply at the starting line. The task of turning the rhetoric and good words into reality is Herculean, and all our attention should be focused on it. Central to this will be political will and sustained financial investment, along with far better data and much sharper accountability mechanisms.
I previously welcomed the government commitment to spend an extra £1 billion on mental health in 2020-21. I noted, however, that that extra money will come through only in 2020-21 and that in the years preceding, significantly less money will be available. Indeed, mental health services will be expected to make significant savings alongside the rest of the NHS. So when summing up, will the Minister spell out precisely how much money will be available in each of the financial years between now and then? We have already heard about the recent survey showing that most providers and commissioners do not feel confident that £1 billion will be sufficient to meet the challenges already outlined, given the historic underfunding of mental health services and the deficits that so many NHS trusts face. Of particular concern is whether this funding will be adequate to roll out the services needed to meet the first ever waiting standards for depression and anxiety and for early intervention in psychosis, introduced by the coalition Government, as my noble friend Lady Brinton told us. What reassurances can the Minister give me on that point?
The task force’s very welcome commitment to introduce comprehensive waiting time standards is critical to bringing mental health in line with physical health and to fundamentally changing the culture. To turn the tanker around, these standards need to be accorded the same status as four-hour A&E targets, cancer waiting times and the 18-hour referral-to-treatment targets. However, the chief executive of NHS England, Simon Stevens, recently confirmed that the £1 billion by 2020 will not be sufficient to deliver comprehensive waiting time standards. Indeed, that assessment was backed up by a recent NAO report which found that achieving the standards would be “a very significant challenge”. In summing up, will the Minister please confirm whether the Government are still committed to fully funding these standards, which are at the very heart of parity of esteem?
Turning to funding for children and young people’s mental health, the additional and very welcome £1.25 billion secured in the April 2015 Budget to back up the Future in Mind report should amount to £250 million in each year of this Parliament. But as we have already heard, in reality, only £143 million was spent in the last financial year, with only £75 million of that going directly to CCGs to improve local services. That raises the question of why there was a delay in getting resources through to the front line of children’s mental health services. I know that capacity issues have been cited by the Government, so will the Minister please say what progress has been made on the workforce recommendations contained in Future in Mind, and when the roughly £100 million funding shortfall in 2015-16 will be forthcoming?
Along with adequate funding, we need far greater transparency about how money allocated at national level reaches the front line of mental health services and which mental health services are being prioritised. Frankly, it is worrying that it took a freedom of information request last year to find out that some 50 out of 130 CCGs were planning to reduce spending on mental health. The recent updated planning guidance from NHS England tells CCGs to increase in real terms their spending on mental health by at least as much as their overall allocation increases, and that is of course welcome. However, it is vital that proper tracking mechanisms are in place to ensure that CCGs are held to account on how much they spend and the impact that is having on their communities. In turn, that calls for far better data collection at local level on spending, including how much is being spent on different types of services and treatments. At present, we have what the Minister himself in this House has called a data black box. That is really holding back progress on the much-needed transparency and accountability.
One of the main ways of holding CCGs to account is the improvement assessment framework, which measures CCGs against specific targets. It was therefore very disappointing that the newly published framework does not include a specific assessment of how much CCGs spend on mental health provision in their areas. That was a real missed opportunity. I fully understand the severity of the overall pressures on CCGs, but they were exemplified most starkly in a rare move recently when the Mental Health Commissioners Network wrote to the Department of Health asking that money for young people’s mental health care be ring-fenced so that it is not siphoned off to pay for other services. I have to say that that is something I personally would support. I understand that the department has replied, saying that it does not have the legal powers to do that, so I turn to the legal position for a moment.
In the debate on the Speech I said that equal access to mental health care should be enshrined in legislation. At present, apart from a general reference to parity of esteem between mental and physical health in the Health and Social Care Act 2012, the only specific pieces of mental health legislation of which I am aware are the Mental Health Acts 1983 and 2007 and the Mental Capacity Act 2005, and they deal with completely different issues. So while I do not generally support the use of legislation to send policy signals, my sense, backed up by everything I have heard in the debate today, is that legislation in some form or legislative underpinning is needed to achieve the fundamental culture change we need.
One way of achieving this, in my view, would be for waiting times and access standards to be included in the NHS constitution and the handbook to it which the Secretary of State and all NHS bodies are required to take account of. Then people would know that it is an entitlement, not an aspiration or a discretionary matter subject to funding and other priorities. At present, waiting times and access standards are contained only in the NHS mandate, which does not have the same status.
I want to end on a slightly more upbeat note and acknowledge that critically important as money, data and accountability are, they are not the whole answer. There is a mindset issue and an issue about working collaboratively. I have the privilege of chairing the Values Based Children and Adolescent Mental Health System Commission, as declared in the register. The commission started its work earlier in the year and will report in September. In short, it is looking at how we can improve the commissioning and delivery of the children and young people’s mental health system to take better account of what really matters to all involved, most particularly the children and young people themselves. What sort of services, delivered in which way and where, would they like to see? We have received wide-ranging evidence from witnesses across the UK and I am particularly encouraged by some of the examples we have heard in different localities where services have been transformed by CAMHS, schools, local authorities and the voluntary sector coming together, collaborating and pooling budgets. The result is that some places have been completely redesigned around the needs of children and young people and their families. This redesign is generally based on a system-wide approach comprising early intervention and preventative services, often based in schools, with schools acting as hubs, working in tandem with target specialist and crisis services, the latter available on a 24/7 basis. Interesting features include a single point of access, no wrong door, open access and far fewer thresholds. Far more young people in these areas are getting the help they need and the money is being spent far more effectively. I look forward to bringing the findings of the commission to your Lordships’ House.
I am conscious that I have asked rather a lot of questions and I am quite happy for the Minister to reply to me in writing on some of them.
Lord Tunnicliffe (Lab)
My Lords, I thank the noble Baroness, Lady Brinton, for bringing this debate to the House, and I congratulate her on such a comprehensive introduction. I will not bore the House by repeating much of the same stuff, because she presented it in such an effective way. I also thank the noble Lord, Lord Oates, for his personal statements about mental illness. We now come into contact with mental illness more readily than we did before, because we are beginning to see the extent to which it is present in society, but we still have a problem in talking about mental illness. It is possibly the last great taboo. Along with these reports, we must give some thought to how we can change that.
The one thing that I have learned in my own life is that the word “normal” actually means average. In fact, there is enormous diversity in human beings, in how they feel, and how they cope with pressure and the depression that sometimes comes from pressure. I have worked in extremely highly pressured situations and I have certainly had days when I have felt that not getting up would be a better idea. I have sometimes wondered whether I was mentally ill. It is getting better, but the taboos of the past meant that if I had sought any help I would have seriously jeopardised my career. It was very much the tradition of my generation that when coming under such pressure one coped with it oneself. One coped with it, frankly, without an education. Perhaps education about mental health would help us to understand it, cope with it better, and help our fellow citizens more.
I believe that we can look to areas of some hope that that would work. Also in my generation the word cancer was almost impossible to express. It was a taboo subject; we did not talk about somebody having cancer. When you knew somebody who had cancer they were almost a non-person. Now, thank goodness, that has virtually disappeared, and as a result there is much more information and people talk to each other about it in a way that is supportive to people who have cancer, which makes early diagnosis and treatment possible.
We have a similar situation with gender issues, which the noble Lord, Lord Oates, spoke about—the culmination, I think, of the new liberal world and gay marriage. The noble Lord, Lord Oates, touched on the issue of talking therapies. I seek assurance from the Minister that the provision of training for talking therapies is not hindered. I understand that it is provided under the auspices of the IAPT. Talking therapies are much more cost-effective in the sense that average workers who are already in the area can be trained to be high value-adding therapists. I hope that there are no inhibitions in the development of these therapies, because, as I understand it, that is one of the limiting factors in spreading them more widely.
I thank the noble Lord, Lord Crisp, for his wider view. I think his most worrying statement was that 50% of providers have little confidence that these additional resources are actually arriving. The noble Baroness, Lady Tyler, reminded us that one in four of the population will have contact in any one year with mental health issues themselves. Once again, I look back curiously at myself and wonder whether I was one of those one in four. She said that the reports taken together suggest a set of documents, thoughts and recommendations, but she put the point to the Minister, which I share: will the resources be there in reality?
The final report on the Mental Health Taskforce, commissioned by NHS England, was published earlier this year. It provides a frank assessment of the state of mental health care and describes a system that is ruining some people’s lives. The report offers several recommendations that could have a significant and progressive impact on the delivery of service to mental health patients. It brings out, as did the noble Baroness, Lady Brinton, that the estimated economic cost of mental ill health is £105 billion in England annually, which is equal to the entire NHS budget in England and accounts for 23% of the disease burden in the NHS. Despite all this, only 9% of the overall NHS budget is spent on mental health.
Since 2014, the Government have announced an extra £600 million for mental health services, £1.25 billion from 2015 to 2020 for children and young people’s mental health, and another £1 billion in the taskforce report. We are concerned that, despite these pledges, the scale of the problem of achieving parity of esteem is extensive. For example, the five-year investment in child and adolescent mental health services equates to barely £1 million per clinical commissioning group each year. This is inadequate when looking at data released in a recent NSPCC report, which stated that out of 186,000 cases referred by doctors from 35 mental health trusts, nearly 40,000 children received no help at all. Does the Minister believe this sufficient not only to tackle the chronic bed shortage and the distribution of such beds across the country but to develop comprehensive prevention and early-intervention programmes?
Before this debate I read the report—not from cover to cover, I have to admit, but parts of it. As the noble Baroness, Lady Brinton, mentioned, the position it describes is pretty terrifying. When I used to run a railway we used to have a suicide attempt a week. About half were successful, so suicides were close to my daily knowledge, as one knew about every event. One would end up giving bravery certificates to staff who had crawled under trains to help people who were not dead. In that sense, suicide has been close to my personal experience. There were 4,882 suicides in 2014. As has been said, that is the leading cause of death in 15 to 49 year-old men. You cannot have a clearer example that something is wrong when people commit suicide. Parity of esteem and the whole issue of equal access are so important.
The challenges of the report have been put to the Minister. I hope that he answers them. I am not too optimistic. That is not a comment on the Minister. We all know that he does his best. But when one looks at the similar debate in the House of Commons, when asked for a response to the report, the Minister for Community and Social Care, Alistair Burt, in the middle of a very long answer, said this:
“I spoke to the taskforce after the issuing of the report. I do not particularly want just to produce a response to the taskforce report; I said that I would prefer a series of rolling responses, as it were, so that when we have responded to a recommendation and when we are moving on and delivering on it, I would say so. That will come in a variety of different forms, but will be related to what the taskforce has done. That may well involve announcements to Parliament, whether by written ministerial statements or other means. I did not want one big bang of a response”.—[Official Report, Commons, 23/2/16; col. 155.]
I think we do want a big bang of a response. We want a comprehensive response to the reports and we want to know what the Government are doing. We want the figures to be much clearer. We want to know that the resources are going into metal health to make parity of esteem a reality.
The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, I thank the noble Baroness, Lady Brinton, for tabling the debate. It is a pity that it is right at the fag end of this sitting because it is a hugely important issue. Whether it is once or twice a year, we ought to be held to account. It is so important. At a time when the health service is going through very difficult financial times, it will be easy to fudge some of the numbers. It is important that we are held to account for what we say will do. I thank the noble Baroness for bringing the debate here today.
The noble Baroness said that this was a funding issue and of course it is—up to a point. We have won a big argument over the last few years that preceded the funding issue. We should not underestimate how far we have come in this debate about mental health. It was very moving to hear the personal story of the noble Lord, Lord Oates. Society has come a heck of a long way since Section 28 of the Local Government Act, or whichever Act he referred to. The gender issues are largely behind us—but not fully so. The noble Lord, Lord Crisp, said that there was still prejudice around not just race but also homophobic issues. We should not be complacent about this but society has moved a heck of a long way over the last 20 or 30 years. We are slowly winning the argument that mental health care should be treated truly with parity with physical health care. Although I subscribe to the old saying that fine words butter no parsnips, fine words made a difference in this area of healthcare.
All speakers have shown just how important mental health is. As the noble Baroness, Lady Brinton, said, nearly all of us have someone very close to us—it may be as close as ourselves, as in the case of the noble Lord, Lord Oates, but it might be members of our families, children or friends—who have suffered the devastating consequences of poor mental health. The story of the 16 year-old girl kept in a police cell for 48 hours having committed no crime except that she was mentally ill is just one indication of that. But this is in part no longer a taboo subject because of the bravery of people such as Alastair Campbell and Stephen Fry. Some noble Lords will have read the obituaries of Sally Brampton in the papers last week; she took her own life after a lifetime of struggle with depression. I was particularly struck to read in one obituary that she had said that when you are depressed you do not know if it is your nature or your biology. That goes to the fundamental essence of depression. You do not know whether you are a bad person. Of course, it is often a question of biology and genetics, and of the environment you are in. The noble Lord, Lord Oates, talked about the strength of his family and friends that got him through a really difficult time.
I was struck by the comments of the noble Baroness, Lady Tyler, about health inequalities. She referred to Michael Marmot. Frankly, many of these issues go way beyond the NHS. We spend all our time talking about the NHS and so many of our health inequalities stem from poor housing, a lack of family support, unemployment, poverty and so on. It is interesting how much time we spend talking about the NHS when so much of what needs to be done in healthcare lies well outside the health system.
The noble Lord, Lord Crisp, made the fascinating point that globally mental health attracts 1% of funding but causes 25% of disability. He asked whether DfID could look at parity of esteem as well. That is a very interesting point and we should look at that. He made three other points, including on out-of-area treatment. That point was also mentioned by other noble Lords. When you have ill people being transferred not just for very specialist treatment but for general acute treatment—as he put it—that is a highly unsatisfactory situation. First, people may be admitted into an incredibly busy A&E department of an acute hospital. Often the situation in the A&E department is chaotic and people do not get the kind of one-on-one special support that they need. They then get put on a ward, where there is general chaos as well. They are just not kitted out to deal with people going through a psychotic interlude. The staff desperately ring round for beds in the county the patient happens to be in but they cannot find any. Then they find a bed somewhere else and by the time the patient gets there, that is taken and they end up in a bed somewhere else.
Meanwhile the patient’s family is at home, wherever that is, while the patient is transferred from one place to another. When he or she finally gets a bed, sometimes they are not assessed for days. Sometimes people can buy their way out of this. One noble Lord talked about CAMHS. Someone with money who has an eating disorder, for example, can sometimes buy their way out of reliance on state provision, but, of course, that is not available to many people. One of your children or friends may be being treated many miles away from where they live—that is, if they get a bed in an eating disorder unit.
The foreword of Paul Farmer’s report states:
“For far too long, people of all ages with mental health problems have been stigmatised and marginalised, all too often experiencing an NHS that treats their minds and bodies separately. Mental health services have been underfunded for decades, and too many people have received no help at all, leading to hundreds of thousands of lives put on hold or ruined, and thousands of tragic and unnecessary deaths”.
That is the background to this issue. We have to recognise and be realistic about how long it will take us to get from where we are to where we need to be. It will not happen in a couple of years but over a longer period than this Parliament, I suspect.
I was very moved by the words of a patient, as cited by the noble Lord, Lord Crisp. So often it is the patient’s story that makes the argument. I also cite the words of a patient, as follows, “I returned to hospital from leave but there were no beds available so I had to sleep in a common room. There was little privacy, no lock on the door, no frosted glass. People often just wandered in, thinking it was a public room and I had to create my own makeshift curtains. The room stank of cigarettes. The floor was dirty and the only storage place I had was a small bedside table. Despite constant complaints from me regarding the room, I was expected to put up and shut up. I would have had better treatment in jail”. That is just one person’s experience of the mental health system.
So we are a long way away from parity of esteem, if we are honest, and it will take us a long time to get there. But that is no excuse for not trying as hard as we can and no excuse for not holding this Government to account for the promises they make. Before I come to the commitments that we have made, I will refer to the eight principles that Paul Farmer thought should underpin reform. Decisions must be locally led. Care must be based on the best available evidence. Services must be designed in partnership with people who have mental health problems and with carers. Inequalities must be reduced to ensure that all needs are met across all ages. Care must be integrated, spanning people’s physical, mental and social needs. Prevention and early intervention must be prioritised. Care must be safe, effective and personal and delivered in the least restrictive setting, and the right data must be collected and used to drive and evaluate progress.
Getting the data was referred to by the noble Baroness, Lady Tyler. She has made that point before. It is a black hole because without the data you do not know where you are. One thing that has absolutely come home to me over the past year is that if we are going to address the unwarranted variation that exists across the country, which is as true for physical health as it is for mental health, we have to have the data. If we are going to have waiting times enshrined in the constitution or legislation or anywhere else, we have to have the data —and, frankly, we do not have the data at the moment. So getting the data has to be an absolute priority.
Turning to the commitments we have made in support of parity of esteem, the 2015-16 planning guidance made it absolutely clear that CCG allocations must increase by at least the amount of the overall allocation, which was 3.74%. Half way through the year it looked as though that was growing by about 5.4%. The planning guidance for 2016-17 is that commissioners must continue to increase investment in mental health services each year at a level which at least matches their overall expenditure increase. Your Lordships must hold us to account for that. That is what we have said we are going to do in 2016-17. If the money is not getting through to providers, as the noble Lords, Lord Crisp and Lord Tunnicliffe, said, then it should be getting through to providers and we have an obligation to make sure that it does.
I will write to noble Lords about the tangible commitments we have made. The noble Baroness, Lady Tyler, said before the debate that she would prefer me to write, and I do not think there is any point in me giving the figures now. I have got the annual figures but rather than read them I will write to everyone who has contributed to this debate, setting out the figures on a year-by-year basis. In summary, we are committed to spending £1.4 billion on children and young people’s mental health and eating disorders over five years. Of that £1.4 billion, £150 million is earmarked for eating disorders. In January this year the Prime Minister made a commitment to spend £1 billion over the period to improve perinatal mental health, mental health liaison services and 24/7 crisis care. In the Five-Year Forward View for Mental Health, Paul Farmer’s recommendations totalled £1 billion by the end of the period. I will write to noble Lords setting out clearly what those figures are. What they will show is that at the end of the period, we should be spending more than an additional £1 billion and another £300 million a year, I think, on children’s mental health.
In conclusion, we are absolutely committed to delivering better mental health care over the next five years, but your Lordships will have to have some patience with us: it will not happen overnight.
Baroness Brinton
My Lords, I thank everyone who has contributed to the debate, particularly to my noble friend Lord Oates for his personal story, which reminded us that strategies and data all come down to individuals. I am particularly grateful for his comments about children out of school, which is an interest that I have as well.
I am grateful to the noble Lord, Lord Crisp, for making sure that we remember that mental health issues are global, not just local, and I support his plea that DfID, too, should look at parity of esteem. I hope that the Minister will pass that on to DfID. I am grateful, too, to my noble friend Lady Tyler for her proposals for ring-fencing. I hope that the Minister will be able to address that in the reply to my noble friend. Despite the reassurances that the Minister has just given us, there is clearly real concern among providers, and even among some CCGs, that funding is not getting to front-line services. We need to be reassured that that will happen.
I am very grateful to the noble Lord, Lord Tunnicliffe, for talking about changing taboos, which is absolutely vital. We move at glacial speed on some things, and although progress is being made, if you talk to young people in particular, some major taboos are still there. Education and PHSE play an important role in helping our young people to understand how they might upset other people and in helping those young people who face difficulties to put their own experience in front of their friends and to be able to talk about it. The noble Lord, Lord Tunnicliffe, quoted Alistair Burt about rolling responses rather than one big response. I share his concern on that.
I am very grateful for the comments of the noble Lord, Lord Prior. Everybody who has taken part in this debate would completely understand that the noble Lord is certainly sympathetic to the issues about mental health, as I think is the Department of Health. But the funding issues remain, and I think we all look forward to receiving the details. Following his offer to hold the Government to account for delivering them, I also hope that he will be able to go back to the Treasury with the comments made in this debate to argue for further and specific resources. On that basis, I beg to move.