Five Year Forward View for Mental Health

Tuesday 30th October 2018 Westminster Hall

[Mr Philip Hollobone in the Chair]

16:00

[Jeff Smith (Manchester, Withington) (Lab)]

I beg to move,

That this House has considered the five-year forward view for mental health.

It is a pleasure to serve with you in the Chair, Mr Hollobone. The key purpose of the debate is to represent the recent report of the all-party parliamentary group on mental health, of which I am vice-chair. We published “Progress of the Five Year Forward View for Mental Health: On the road to parity”, which is a report on the progress of the five year forward view at the halfway stage.

I pay tribute to the cross-party group of MPs and peers who took part in the inquiry, particularly the hon. Member for Faversham and Mid Kent (Helen Whately), who is the chair of the APPG; she is with us in this debate and I think she will make some remarks. I also pay tribute to Rethink Mental Illness and to the Royal College of Psychiatrists, which provided us with excellent secretariat support and supported us throughout the inquiry. I thank the Secretary of State for Health and Social Care, who attended the parliamentary launch of the report and engaged in a very helpful question and answer session.

The report is a summary of more than 70 pieces of written evidence, two oral evidence sessions, a focus group of service users and carers, and a visit to a mental health trust. It is a serious and informative piece of work that could help to make a difference in informing the NHS’s long-term plan. There are three main sets of recommendations in the report, including some important ones on joining up work with other services, particularly social care and housing, but this is quite a short debate so I will focus only on two questions.

I am interested to hear from the Minister about the Government’s plans to support people with severe mental illness. The report shows that adults severely affected by mental illnesses such as schizophrenia or bipolar disorder are left behind. We saw no consistent and coherent approach on how to support people diagnosed with personality disorders. The inquiry heard that there are no targets for how long adults should have to wait to access eating disorder services. Those illnesses have a severe impact on people’s day-to-day lives and can be lifelong conditions. It is not acceptable that people who are the most ill often wait the longest to get care.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Gentleman on securing the debate. Although I appreciate, as he will, how big a task this is, I welcome the Government’s commitment to mental health funding in the Budget. But I am concerned that we are getting nowhere in reaching parity of esteem. The number of children and young people experiencing mental health problems has risen sharply, and they often go to A&E for help. Does he share my view that funding is needed to ensure that children and young people suffering with poor mental health have safe places in the community to turn to for help and support, without having to rely on A&Es, which are already under duress?

[Jeff Smith]

I very much agree with the hon. Gentleman. Although I will never say that increased spending on mental health is not good, the announcement in yesterday’s Budget of extra funding for mental health teams in A&Es points to a problem because we should not have to increase spending on A&Es. We should try to cut the number of people who have to go to A&Es at an earlier stage, and we must invest at an earlier stage.

[Rachael Maskell (York Central) (Lab/Co-op)]

I am very grateful for the APPG’s work. One of the biggest concerns is about mental health support in further education colleges, which seems to have gone completely off the radar. Both colleges in York have told me that there is increasing crisis in further education, particularly on self-harm by young people—now that there are more exam-based assessments, that is escalating at a pace. Does my hon. Friend agree that we must focus on prevention in FE colleges, to ensure we have the right health professionals based in those colleges?

[Jeff Smith]

I absolutely agree with my hon. Friend. Child, adolescent and early adult mental health is a big and growing problem.

The five year forward view recognised creating treatment pathways for people with bipolar disorder, adult eating disorders and personality disorders, but halfway through the plan, the inquiry found that those are still to be published. It is vital that NHS England implement in full all pathways recommended in the five year forward view.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I congratulate the hon. Gentleman on securing this debate. I draw Members’ attention to my entry in the Register of Members’ Financial Interests. Although there has been a commendable focus on increasing talking therapy through the IAPT—improving access to psychological therapies—programme, that tends to be cognitive behavioural therapy. The evidence base for helping people with personality disorder, particularly emotionally unstable personality disorder, is dialectical behaviour therapy. There is a real paucity of other talking therapies such as DBT available throughout the country, but particularly further north than where we are sitting, in London.

[Jeff Smith]

The hon. Gentleman has great experience and knowledge of those issues and makes an important point. He has anticipated some of the comments I will make and I strongly agree with him.

[John Howell (Henley) (Con)]

We, as MPs, are among the first to come across the sort of patients the hon. Gentleman is talking about. Does he agree that training ought to be provided for MPs, so that we know how to deal with those people when they appear at our surgeries?

[Jeff Smith]

That is an excellent point; some training packages are available for MPs’ staff. I encourage all colleagues to take advantage of that.

The vast majority of people severely affected by mental illness will receive support within a community mental health team, which is the type of core service that provides help to around 700,000 people in England, often with quite complex needs. Although some specialist services have benefited from additional funding and targets, core services for adults severely affected by mental illness have stood still. Core community services did not receive any funding under the five year forward view, and we found that only £50 million was allocated to other core services nationally.

[Mike Hill (Hartlepool) (Lab)]

In Hartlepool, there is no drop-in centre for people in crisis. Crisis teams are stretched to the limit, and often people wait for two hours or more to access them. Given the current funding review, does my hon. Friend agree that we must urgently resolve such situations?

[Jeff Smith]

Again, that is an excellent point and I strongly agree. The report makes it clear that core services are underfunded and under pressure. There has been great success in getting people better access to psychological therapy, but while IAPT is an excellent service it is not designed for people with severe mental illness. Core services are too overstretched to provide timely talking therapies to people with more complex needs, so those who are most ill often have to wait the longest to get help. Simon Stevens, the head of the NHS, said at the Global Mental Health summit that he believed that we must restrike the balance between new talking therapy services for patients with less severe conditions and the core services for those with long-term and severe mental health needs.

We heard many examples of people with severe mental illness struggling to get therapy. One service user came to us; they had a history of psychosis and were told by their GP that if they wanted to access psychological therapy quickly, they should lie to the IAPT team about having psychosis to avoid being rejected for treatment, because it was too difficult to get the treatment they needed for their condition.

In the worst case scenario, people can be hit with the double whammy of being told they are too ill for IAPT but not ill enough for a core mental health team. People are then left struggling. Another service user, Dani, who has a diagnosis of borderline personality disorder, spoke at our parliamentary launch and contributed to the report. She said that she felt it was strange to be called a service user because her experience was mostly of being told that she was not suitable for services, rather than actually using them.

The inquiry saw the consequences of what happens when people do not get timely support in the community. First, there is a rise in inappropriate out-of-area placements. At the end of June this year, there were 645 inappropriate out-of-area bed placements. Secondly, there is a rise in mental health crises. The report notes that attendances at A&E for a mental health problem have risen 94% since 2010. In our inquiry, we heard from service users who expressed their frustration at turning up at A&E and waiting hours to be seen, before being sent home after a brief chat with a professional. Extra services in A&E, as we were promised yesterday, are positive but a much better solution would be intervening so people do not have to go to A&E. A model already exists where mental health calls to 111 or 999 are redirected to a specialised 24/7 support service staffed by experienced psychological wellbeing coaches, social workers and mental health nurses, who can provide assessments and real-time support. That is successful and it could be rolled out as a national standard approach, which is something the report recommends.

Mental health crises should not be considered an inevitability for people severely affected by mental illness. It is entirely possible to stop people having to go to A&E in a crisis if community services intervene early enough to support them. Support across the country is patchy, unfortunately, as core services struggle to meet the increased demand on budgets. We should not be creating a system that steps in only when people reach breaking point. That is why the report recommends that NHS England should increase resources for core mental health services, such as community mental health teams. Will the Minister set out how the Department of Health and Social Care will help people with severe mental illnesses who are being left without support?

Secondly, I would like to focus on the issue of workforce. Will the Minister set out how we will ensure that we have the staff to meet the needs of everyone with a mental illness? Throughout the inquiry, we heard regularly that the issue of workforce is the biggest barrier to achieving the five year forward view. When workforce and funding for them do not meet demand, the thresholds for accessing treatment rise. That is a problem not just in core services, but in child and adolescent mental health services and across the board.

[Dr Poulter]

The hon. Gentleman is again making an important point. It is all very well talking about the aspiration of putting more money into mental health and expanding services, but improvement cannot be delivered without the workforce on the ground to provide care. There are serious recruitment and retention challenges across the mental health workforce. If we are talking about the crisis with young people, there is a real problem attracting people into the CAMHS workforce, particularly to become CAMHS consultants and CAMHS psychiatrists. That is an issue that the report picks up in great detail, but I hope he will join me in urging the Government to address this as a matter of urgency.

[Jeff Smith]

The hon. Gentleman makes another excellent point. Health Education England’s plan commits to 19,000 more people working in mental health by 2021, but between March 2017 and March 2018 the number of mental health staff in the NHS increased by just 915 people. That does not look like progress is on target. One in 10 consultant psychiatrist posts is empty and between April 2010 and 2018 there was a 12% fall in the number of mental health nurses. What are the Government’s plans to tackle the problem of the mental health workforce?

The report makes some recommendations and suggests that Health Education England and the Government look at all measures to increase the mental health workforce. There is a huge interest in mental health among young adults. Until we undertook the report, I did not realise that psychology was the third most popular undergraduate course for students starting university in 2016. We should make it easier for those capable, ambitious and keen graduates to work in NHS mental health services.

The hon. Member for Central Suffolk and North Ipswich (Dr Poulter) made the point earlier that recruiting more psychologists for specific therapies, such as dialectical behaviour therapy or cognitive analytic therapy, would mean that people had a wider choice about the type of therapy they received, instead of, as often happens, just being prescribed cognitive behavioural therapy—if they are able to get a prescription at all—because it is the only therapy available.

[Danielle Rowley (Midlothian) (Lab)]

As well as having more specialists in the NHS, does my hon. Friend agree that to tackle mental health we need good training in schools, workplaces and all the different parts of society? The point was made earlier that we, as Members of Parliament, need to have training, as well as being able to encourage a more positive attitude to mental health.

[Jeff Smith]

My hon. Friend makes an excellent point. I am probably not going to take any more interventions because I want to give the chair of the all-party parliamentary group on mental health time to make remarks and to hear from the Minister. I will rattle through the rest of my comments.

The report suggests that the peer workforce, where people with their own personal experience of mental illness support those who are currently in mental health services, should be expanded. Service users told us that it was invaluable not only in terms of positive role models, but to prevent an “us and them” barrier between patient and professional. It is effective and leads to a reduction in readmissions.

Finally, funding—the elephant in the room, as always. The five year forward view came with a headline commitment of over £1 billion invested each year in mental health by 2021. This has undoubtedly improved lives. However, the APPG heard that it is difficult to be certain that funds are reaching the frontline and that historical underfunding means that mental health is still the poor relation in the NHS. I note that a report from the Institute for Public Policy Research suggests that spending on mental health will have to double from £12 billion to £23.9 billion in the next decade to make parity of esteem a reality.

The mental health investment standard means that every clinical commissioning group has to increase mental health spend in line with its overall increase in health spending. However, last year, 24 CCGs reduced the amount they spent on mental health. Eight CCGs were classed as meeting the mental health investment standard despite the fact that they cut the amount they spent on mental health. We would welcome clarification on what the Government are doing to ensure that each CCG meets that target.

The five year forward view was never intended to solve every problem in our mental health system, but where it has been focused it has made a difference. For example, there has been success in perinatal mental health and improving access to IAPT. This report focuses on where the gaps are. We need to prioritise investment in core services and to ensure that we have a robust NHS workforce. I hope that the Minister, with NHS England, will respond positively to the report and hopefully this will reform NHS long-term planning.

16:18

[Helen Whately (Faversham and Mid Kent) (Con)]

I sincerely thank the hon. Member for Manchester, Withington (Jeff Smith) for giving me a chance to speak in the debate, as that was entirely at his discretion. It has been a real pleasure working with him on the report. I also reiterate his thanks to Rethink Mental Illness and the Royal College of Psychiatrists, which have done a huge amount of the work that has been condensed into the report. A great deal of hard work went into it, and they did most of the legwork.

I have been on quite a journey with this report. We originally conceived it back in 2016 and it came to fruition this year, at a moment that feels timely because we are mid-way into the five year forward view. NHS England is working on its long-term plan for the NHS and I hope it will be drawing on the recommendations in the report. The Chancellor has just announced a welcome £2 billion of funding for mental health out of the £20 billion for the NHS.

During the inquiry we heard about some areas of mental health where real progress has been made. We heard some truly inspiring success stories of how the five year forward view and the changes in it are changing people’s lives. For instance, we heard about new perinatal services—four new mother and baby units—which mean that when a mother is severely ill, she will be able to receive in-patient treatment and have her baby there with her, rather than their being separated, as has too often been the case in the past.

We heard about the success of talking therapy services and how many people are getting timely access to them. We also heard about the success of early intervention in psychosis. In the past, a diagnosis of psychosis could be seen as a life sentence, but early intervention really does make a difference and we heard success stories of people recovering and going on to lead mentally healthy lives.

Although there are some real success stories, there is much more to do. The report makes 24 recommendations, but given the time I will mention just three of them. There will be a little bit of repetition of what the hon. Member for Manchester, Withington said, although I will try to avoid it as far as I can, but I think it is worth emphasising these three areas.

First, the report includes the recommendation that the Government develop evidence-based treatment pathways more widely. We heard from the eating disorders team at North West London NHS Foundation Trust that having firm waiting time targets and a clear pathway for treatment had immeasurably improved care, but although the five year forward view included a timeline for creating treatment pathways across all areas of mental health, there are many areas where they have not been implemented.

Secondly, the question of workforce came up time and again as the biggest barrier to achieving the ambitions of the five year forward view for mental health. There is a desperate need to train, recruit and retain more staff at every level. We simply cannot make meaningful improvements to services without the staff to deliver them; there must be new routes into the NHS workforce, making use of psychology graduates—as has been mentioned—and psychotherapists, and bringing in more people with lived experience of mental illness, who do valuable work. It is also important that all frontline staff get some mental health training.

We heard that mental health training now forms a greater part of the training for new nurses and doctors, for instance, but there is a huge established workforce who could benefit from at least some mental health training. We heard from one carer who had done a mental health first aid course and said she had more of knowledge of mental health than her sister, who was a nurse.

Thirdly, core services are truly the backbone of mental health care. We heard that they are consistently struggling to cope with demand, leaving more people unable to get help until they reach crisis point. The focus on some of the new, exciting services has perhaps meant that the focus has turned away from those vital core services.

To sum up, great progress has been made. We are on the road to parity between mental and physical health. I feel optimistic because of the Government’s attention to this agenda and the extra funding coming in for mental health, but there is indeed some way to go.

16:23

[The Parliamentary Under-Secretary of State for Housing, Communities and Local Government (Nigel Adams)]

I congratulate the hon. Member for Manchester, Withington (Jeff Smith) on securing the debate and all hon. Members present on their contributions and interventions.

Improving care and reducing the stigma around mental health is a key priority for this Government. We welcome the report from the all-party parliamentary group, and I congratulate both the vice-chair and the chair on their work. I think my hon. Friend the Member for Faversham and Mid Kent (Helen Whately) probably underplays the amount of effort that she and her vice-chairs put into it. The report is a timely piece of work and a well-considered contribution to the dialogue on mental health services in this country. In many ways, it mirrors the thinking we have already seen from Mind, the Royal College of Psychiatrists and others.

The statistics on mental health demonstrate the size of the challenge we face. One in four adults experiences at least one diagnosable mental health problem in any given year, yet NHS support for mental ill health has historically been seen as a “Cinderella service”, of secondary importance to other NHS services. The stigma attached to mental ill health has, at times, led mental health service users to feel marginalised.

That is why, in 2016, the Prime Minister made a commitment to improving mental health services. As has been mentioned today, we set out to achieve greater parity of esteem between physical and mental health services. In February 2016, NHS England published “The Five Year Forward View for Mental Health”. This is a timely debate in that regard; I suspect we could have done with an hour and a half at least, and I am sure that when the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Thurrock (Jackie Doyle-Price), returns to her post there will be an opportunity to expand the debate.

The five year forward view was the result of wide-ranging stakeholder engagement, led by an independent mental health taskforce and chaired by Paul Farmer, chief executive of Mind. It laid the foundations for what we believe to be one of the largest transformation programmes for mental health services anywhere in Europe. The transformation may not be complete, but as my hon. Friend the Member for Faversham and Mid Kent said, progress has been made, and continues to be made.

I will just touch on funding, which formed a key part of the remarks made by the hon. Member for Manchester, Withington. To support the commitments made in the five year forward view, we have pledged £1 billion for adult mental health services between 2016 and 2021. That came on top of the £1.4 billion pledged the previous year in recognition of the need radically to improve children and young people’s mental health services.

We have delivered against those funding commitments: last year saw more than ever before spent by the NHS on mental health, with almost £12 billion spent by clinical commissioning groups and on specialised services, such as those for eating disorders. Only yesterday, right hon. and hon. Members will have heard the Chancellor’s announcement of a further £2 billion to fund mental health by 2023-24, expanding crisis services and supporting more people with severe mental illness into employment.

Today, 74% of people referred for treatment following a first episode of psychosis receive treatment within two weeks under the early intervention in psychosis programme, compared with 64% only two and a half years ago. Just under 80% of routine eating disorder referrals are seen within four weeks, compared with 65.1 % only two years ago. In 2017-18, the national trajectory of 2,000 more women accessing specialist perinatal care was exceeded and we continue to focus on developing local, integrated pathways in this area.

Things are improving outside NHS settings too. We have heard about the work that should be taking place in colleges—importantly—and workplaces. Our investment in improved facilities for crisis mental health care and changes to legislation have helped to reduce, for example, the number of people detained in police cells following a mental health crisis by more than 95% compared with 2011-12. I am pleased that the report recognised some of those achievements over what has been called a “transformational” period in the history of mental health services in this country.

Referring to what my hon. Friend the Member for Faversham and Mid Kent said about core services, we recognise that there is still much unmet need in mental health. That is particularly true for those suffering severe mental illness. Across the country, we are seeing innovative examples of community mental health services working well to provide timely support close to home, to help prevent in-patient admissions.

We also need to look beyond the NHS. Public attitudes towards mental health are improving. That is in part due to the Time to Change campaign, for which this Government provided £1 million of funding. We want to be recognised as a global leader when it comes to mental health, which is why, only three weeks ago, we hosted the global inter-ministerial conference.

I know time is running out, so let me turn quickly to some of the other remarks made by the hon. Member for Manchester, Withington on workforce. We have committed to 21,000 new posts, which will ideally be filled by 19,000 NHS staff. That has been written into local plans and some local areas are making progress, but it is too early to be able to count the number of people in post. The hon. Member for York Central (Rachael Maskell) mentioned further education, and as part of the Green Paper on children and young people we will incentivise every school and college to identify and train a senior designated lead for mental health issues.

To conclude, given the time available, we recognise that there is still much work to be done. I am proud of the work that this Government are doing to improve mental health, ensuring that many more people can access vital, high-quality mental health support. I hope we get an opportunity to debate the subject in future, but I also hope I have provided reassurance today that we are absolutely committed to delivering against the commitments set out in the five year forward view for mental health.

Motion lapsed (Standing Order No. 10 (6)).