(10 years, 6 months ago)
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Lord Layard
That this House takes note of the implications of parity of esteem for mental and physical health, as required by the Health and Social Care Act 2012.
Lord Layard (Lab)
My Lords, by an extraordinary coincidence, today is World Mental Health Day, so I wonder whether it is not due to ballot rigging that we are having this debate today. This is also the time when the Government are preparing the next mandate for the National Health Service, so the timing of this debate could not be better.
Of course, we would like to be in a situation where we did not need to debate parity of esteem, but I start from one simple fact. We have 6 million adults in England suffering from depression or crippling anxiety disorders, and of them only a quarter are in treatment. You can compare that with people with physical conditions where, in most cases, more than 90% are in treatment. The same is true of children: only a quarter of those who would be diagnosed as mentally ill are in treatment. That is not parity of esteem; it is a really deplorable situation. What is the reason? The reason is the lack of parity in the provision of care; that is the central reason.
Of course, medication is available for most people who come forward with those problems, but most of them would prefer, or would want in addition, psychological therapy. We have excellent psychological therapies with 50% recovery rates for anxiety and depression conditions, for children’s disorders and so on, and NICE has reviewed all of them and recommends that psychological therapies ought to be offered to all patients with mental health problems. However, that recommendation is largely disregarded in huge areas of the country where those therapies are not available. Let me give just one extra argument why they should be available—other than the obvious humanitarian argument that we should treat people who are ill; that is why we have a health service. In this case, there are also huge savings to be had if we treat them. Those savings in welfare benefits and extra taxes would pay for the cost of the psychological therapy. That is a complete, 100% offset. Another probable 100% offset is in the cost of additional physical care that mentally ill people demand.
So the argument for making those therapies available is overwhelming, but it is happening very slowly. As Sir Mike Rawlings, the former chairman of NICE says, this is the area in the whole of the NHS where NICE recommendations are the most flagrantly and casually disregarded. If the same thing happened with cancer or heart disease, there would be uproar. That is why what happened in this House two years ago was so important. It was the landmark moment for millions of people because the amendment that we passed in this House introduced the principle of parity between mental and physical health. The issue that we must discuss today is what that means. That was not said in the Bill. We need to discuss exactly what that means and how we would know if we got there.
I want to suggest two simple principles. First, NICE guidelines should be as faithfully implemented for mental illness as they are for physical illness. That is a very simple principle. Secondly, treatment should be provided speedily when it is needed, as it generally is in the case of mental illness. Those two basic principles should guide the way forward. How do we get from here to where we need to be? The mandate, which is now under discussion, is the key. I very much hope that the Minister can help us with some improvements in the draft of the mandate which has been circulated for comment.
Let me start with waiting times. It is shocking that there are waiting times for hospital treatments and no waiting times for psychological therapy. This is not acceptable. Depression and anxiety are pressing conditions; more pressing than some physical conditions, although obviously less pressing in most cases than cancer. With cancer we talk about two weeks. It seems clear that we should be aiming at a maximum wait for access to psychological therapy of 28 days. Many people have argued this. I very much hope that that can be included in the mandate.
Of course, that raises the question of what scale of service would be needed to achieve that objective. The main provider of psychological therapy in the NHS is Improving Access to Psychological Therapies—the programme known as IAPT, launched in 2008. It has been very energetically and faithfully supported by Ministers from all political parties, for which everyone is extremely grateful. The programme grew rapidly, but 80% of those treated still wait for more than 28 days. Some wait for more than 12 months. Waiting lists are rising as people become aware that there is some hope in their lives.
How large a service is needed to implement the NICE guidelines for all who need them? By 2011, in the third to fourth full year of the programme, the programme was seeing more than half a million people. But that of course is only 10% of the 6 million with the condition. Since 2011, the programme has stalled due mainly to poor priorities on the part of local commissioners, the dislocation of the messages coming down to them and the pressure on them from the higher levels of the NHS as it is being reorganised.
I think we can all agree that 10% is a completely unacceptable figure. The Government have already committed to 15% by 2015, but even that deals only with the tip of the iceberg. From our experience in the first three and four years of the programme, it would be feasible to reach a figure of 25% by 2020. I would urge the Government to be thinking in those terms.
The Government, rightly, will want to have people not only treated but recovering. That is the right way to be thinking and that is where the IAPT programme is so strong because we know how many people recover. Patients are monitored on a meeting-by-meeting basis and there is now a 45% recovery rate for the patients who have two or more sessions. The Government target is 50% and the right way to express a vision for 2020 would be the numbers of people who have recovered as a result of treatment.
So I hope that the Government will be giving some indication of that longer term perspective in the mandate. It is really important because we can get good people to train as therapists for the service only if they see that the number of jobs will go on expanding. We will get commissioners to commission this service at an expanding rate only if they see that they are expected to do that and block in increasing sums. Too many of these commissioners have concluded that they have done what they need to for IAPT, which is how it has stalled. It has to be restarted, so I urge the Minister to include at least some phrase in the mandate, if he can, such as “continuing expansion of access up to 2020, linked to 50% recovery rates”. Some phrase of that sort would show that the Government and the service are serious about this. We know that the good will is enormous towards IAPT on the part of the coalition Government, but can they please set this down in some concrete way that commissioners can read and see that they have to act on?
There are of course financial constraints and commissioners are always tempted to dumb down in areas which look like soft targets. Incredibly, one commissioner will not pay for any patient receiving more than two sessions unless they can be shown to have recovered. This is an outrage but there are many who will pay only up to a maximum of six sessions for any one patient, as if they would cut an operation short if it happened to need more than the standard time. This is absolutely unacceptable discrimination and it is rife throughout the commissioning system. How can we deal with it? It would be by pressure of all kinds from above and, of course, with a constant emphasis on outcomes. I place great hope on the measurement of outcomes as the ultimate source of pressure on commissioners. When we get to outcomes-based payments, which we may in a few years’ time, we must again resist the pressure to dumb down by leaving the tariff price free for the local commissioner. There has to be the national reference cost, otherwise this will again be the soft area which gets dumbed down.
I have one final comment on the IAPT programme. It is currently in the list of 10 services suitable for “any qualified provider” treatment, together with incontinency services, wheelchairs and a few other things. Is the treatment of depression and anxiety really worthy of being treated like that? A recent study from the World Health Organisation compared the disabling effect of depression with that of angina, asthma, arthritis and diabetes. I hope it is not surprising to Members of this House that depression was 50% more disabling than each of those four conditions. One wonders why those four were not included in the list, together with incontinency and wheelchair services. If there is confusion about parity of esteem at the centre, no wonder there is even more confusion at the local level.
I have concentrated on depression and anxiety disorders. There are many other mental health problems for adults, and of course for children as well, which I am sure other noble Lords will talk about. But I want to mention just one general point: research. According to the WHO, mental illness accounts for 38% of all illness when weighted by severity in this country and 23% of the total burden of disease, including premature mortality. But what percentage of health research goes on mental health? It is 5%. We need much more mental health research. We need more trials on therapies other than CBT and many more on therapies for children. For adults we do not even know about effective group treatment, which could be very economical and effective compared with individual treatment, and so on. Most trials in mental health are very short follow-ups compared with the decade-long trials for treatment of physical illness. All this should be changed and there should be some statement about it at this point, although it cannot be changed overnight.
I hope that the Minister will reassure us on the four points I have raised—the 28-day maximum wait; the commitment to continued expansion; taking psychological therapy out of the degrading position of coming under AQP, which leads to many of these terrible commissioning decisions; and more research for mental health, especially psychological therapy. We know that the political pressures coming for psychological therapy are trivial compared to the pressures on politicians from those who suffer from most physical illnesses—especially, of course, those which are helped by the pharmaceutical industry—but one third of all families include someone with a mental health problem. Many are silent because of shame, but I think that they will privately thank any politician who shows that they understand their problems.
It is an amazing fact that mental illness, as the surveys show, causes more misery in our society than physical illness does, causes much more than unemployment or poverty do and costs the Exchequer £60 billion. It is extraordinary that it still has such a low priority on the ground. I think that we still live in the materialistic shadow of William Beveridge. As noble Lords know, he identified five great giants—poverty; unemployment; undereducation; poor housing; and physical illness—but he omitted the problems of the human spirit within. This has caused us decades of unnecessary misery. It is time to name the sixth giant, the great, hidden problem in our society, and that is mental illness. If it had parity of esteem, it would have its own Cabinet Minister, like the other subjects I just mentioned. Perhaps the best test of when we eventually have parity of esteem is when we have a Cabinet Minister for mental health. I beg to move.
Lord McColl of Dulwich (Con)
I thank the noble Lord, Lord Layard, for initiating this important debate. As a medical student I was rather surprised to hear professionals refer to patients with psychiatric conditions as “nutters” and “away with the fairies”, among similar comments. As the noble Lord, Lord Layard, said, we do not ridicule people with heart failure or cancer; why do we do it with mental illness? This made me rather interested in psychiatry and I did think of entering that profession, or trying to enter it, but that came to an end when I presented a patient to a psychiatrist, who shall be nameless, having spent a lot of time taking a history from the patient and writing it all up carefully. I started presenting it to the psychiatrist and half way through, he started laughing. I said, “What’s the joke?”. He said, “He’s a psychopath”. I said, “I know he’s a psychopath but what exactly is the joke?”. “Well, we can’t do anything for him.” I thought that was totally inappropriate and I learnt later that the psychiatrists call that “incongruity of affect”. Anyway, that put me off psychiatry.
It is not surprising that people with psychiatric problems feel isolated and abused and find it very difficult to talk about their problems, so all credit to Alastair Campbell, Stephen Fry and others who have spoken openly about their own illness. This has encouraged others to do the same. There is, of course, great misunderstanding about so much of mental illness. Take, for instance, Alzheimer’s. Over the years I have been consulted by many people, some of them in this House, about their relatives with Alzheimer’s and how they find it so irritating that they keep asking the same question and so on. The principles are quite simple: you do not ask a patient with Alzheimer’s any questions and you do not argue with them. When they do things that seem very inappropriate, you ask the question, “Does that matter in terms of eternity?”. I remember that once a patient was frying bacon in honey. I was just a very junior registrar in cooking, and I was not sure if this might be some recent recipe. The meal was delicious; it was impossible to clean the frying pan afterwards, but that did not seem to matter. I have also found it important that they have as much independence as possible. That sometimes means taking risks, but it is well worth it.
In the old days, in the 1950s and 1960s, I found it very difficult to get psychiatrists to come to the accident and emergency department. I do not know why that was, but they would never come. One day I was in trouble and I needed help in A&E. I rang the psychiatric department and a lady answered the phone. When I explained that I was in difficulty and asked her to come and help, she said, “I would be delighted to come”. I nearly fell on the floor; I had never had that response before. She was terrific. Her name was Ros Furlong, and she became a very distinguished psychiatrist. I mention that because it seemed to me that when women started coming into psychiatry, it changed things. Mind you, if you go back to 1945 or 1946, before there were many women in medicine, medical schools were a bit of a rough house. On one occasion a lecture was about to start and ex-Wing Commander Twistington-Higgins said to ex-Able Seaman Smith, who was wearing bell-bottomed trousers, “Smith, you’re improperly dressed”, whereupon ex-Able Seaman Smith stood up, picked up the ex-wing commander and knocked him straight out. However, when women came into medicine, the whole thing became rather more civilised.
My wife had Alzheimer’s for the last five years of her life. I pay tribute to the Maudsley Hospital, which was superb in all its help, especially Professor Simon Lovestone, who is a brilliant psychiatrist and a most kindly man. I got to know him quite well, and I told him the story of how I wanted to be a psychiatrist but was put off by the psychiatrists themselves. He said, “My experience is exactly the reverse”. He had wanted to be a surgeon but he met a psychiatrist called Colin Godber, who was a psychogeriatrician—the crème de la crème of the psychiatric world. Colin Godber asked him if he would like to come and visit a patient at home. They went there, the patient prepared a nice cream tea and then played the piano for half an hour, and then they went home. He said to Colin, “He didn’t seem to be much of a patient”. “Oh no, he wasn’t the patient,” said Godber, “It was his wife. I looked after her, and this week is the anniversary of her death. She died two years ago, and on the anniversary I always go and have tea with him”. Simon Lovestone was so amazed by this that he said, “That’s what I want to be; I shall be a psychiatrist”. It worked the other way round for him.
As the noble Lord, Lord Layard, has mentioned, one-third of the population has had a psychiatric illness. I have often wondered why that is so. A group of 50 ladies in their 40s met, and they all had eating disorders. Each of them told their story, and all of them as children had been sexually abused. At a meeting in No.10 Downing Street some years ago, there were 20 of us in a room discussing this very problem. Without thinking, I said, “Of course, at least 10% of children are sexually abused”. They were horrified and just would not believe it. In fact, one of them said, “There are 20 of us here. Do you mean that two are involved?”. I said, “Well, it does go across the board”. We now know that it is much higher than 10%. We know that one in four women is abused in one way or another, which means that millions of men are smashing up millions of women. It also means that millions of other people know about it and do nothing.
Mental health and well-being is a priority for this Government. The overarching goal is to ensure that mental health has equal priority with physical health and that everyone who needs it has timely access to the best available treatment. We have enshrined in law the equal importance of mental health alongside physical health. The Health and Social Care Act 2012 sets out the equal status of mental and physical health. We have made improvements in mental health and treating mental disease is a key priority for NHS England. One of NHS England’s 24 objectives is to put mental health on a par with physical health and close the gap between the two. On 29 June the Royal College of Psychiatrists published Whole-person Care: from Rhetoric to Reality, which is well worth reading. There is so much to be done in this field and we all have a role to play in encouraging the population to do its bit towards helping with this problem.
Lord Stone of Blackheath (Lab)
My Lords, there is a great deal of expertise here today on this subject. I am no expert, but I have two perspectives based on my particular experiences. The first is as chair of the award -winning health charity DIPEx. We have spent 10 years researching, in depth and on camera through the Health Experiences Research Group at Oxford University, patients’ experiences of illness. We publish them on the internet for free as www.healthtalkonline.org and www.youthhealthtalk.org. We have completed 75 separate modules of different illnesses, each with more than a year’s interviewing.
We have covered a wide range of physical illnesses, including most of the cancers, heart conditions, diabetes and osteoporosis. We have also researched mental conditions such as depression, experiences of psychosis, dementia and life on the autism spectrum, and we are about to launch a recently completed module on the use of antidepressants.
I want to relate here some of the observations from patients’ perspectives. First, patients living with physical, mental and social needs must be seen as actor-agents in their own recovery. The Centre for Mental Health has said that we should ensure that people using mental health services are equal partners in their care and support, with full respect for their needs, wishes and human rights.
Secondly, our senior researcher Susan Kirkpatrick, conducting interviews with the www.healthtalkonline.org patients from the recent antidepressant module to be launched in November, says that while people feel that an antidepressant may be helpful, most say that they benefit most from a combination of medication and therapeutic help. However, the effectiveness of therapeutic treatments seems not to be proven to the satisfaction of those prescribing these medications. The new charity, MQ, has said that to achieve parity of care, we must also have parity of research. MQ is one of the few organisations in the field that does not take sides. It believes that medication and therapies deserve equal research, and says that there is a huge gap between the cost of mental illness and its research funding, as has been mentioned. The UK should capitalise on its role as a leader in research and become one in developing better treatments for mental illness.
Thirdly, as my noble friend has mentioned, for some patients a long waiting time for therapeutic help proves frustrating and even debilitating, and in some mental health cases can be fatal. Here is a disparity. It seems that the system can understand the urgencies in a case of physical illness but with mental illness it feels that the patient can wait. The Centre for Mental Health has observed, as have many people whom we have interviewed, that appropriate waiting times must be established so that people with mental health problems know the maximum waiting time for a treatment, just as people with physical health problems know the longest that they can expect to wait for a treatment.
The NHS constitution has no requirements on waiting times for people with mental health problems, and in particular many psychological therapies are NICE approved and recommended in NICE clinical guidelines. However, due to the NHS constitution, people are not entitled to them in the same way as one is entitled to drugs approved by the NICE technology appraisals. That means that commissioners are not obliged to commission psychological therapies. Even when they do, as has been said, often a maximum number of treatments are prescribed. Can noble Lords imagine, for drugs for a physical illness or chemotherapy, being told, “When you’ve had a maximum of 20 of these injections or radiotherapy sessions, you’re on your own, mate”? Why should that be so for treatment for mental illnesses?
To return to medicines versus therapies, my second viewpoint is from my involvement in mindfulness practice. For centuries we have understood that there are practices we can adopt at an early age for our physical well-being that can be preventive and stop us getting ill, so that even if we contract an illness our physical fitness helps us to recover faster or at least helps us live more comfortably with the condition that we have. We have only recently become aware that the same is true for our mental health. With mindfulness-based practices, one can have a healthier, more enjoyable and productive way of life, and mindfulness can prevent depression and anxiety. It has been proven to NICE that to prevent people slipping back into depression, mindfulness practice can be more effective than drugs or talking methods.
Again, the Centre for Mental Health has said that we need to narrow the gap in the way people’s needs are met in physical and mental health, not only in health and social care but in education, employment and the criminal justice system. A mindfulness strategy for the UK is being designed and developed by my honourable friend Chris Ruane MP and my noble friend Lord Layard and others. It builds upon the work currently being done in this field by universities such as Bangor, Oxford and Exeter. They are working on mindfulness in the education system, for students and teachers in schools and universities, so that it exists in the same way as we have physical training, and are also working in the criminal justice system where, as has been said, we have systemic issues with mental health. Mindfulness practice could be enormously helpful for offenders and police.
Noble Lords may wish to know that in addition to the gymnasium for one’s physical health on the Parliamentary Estate, a mindfulness course operates in this building, including Members of the other place from all parties and a number of Peers. The course is conducted by Professor Mark Williams and Chris Cullen, using their scientifically proven method of training. We have a new series starting here next week, which noble Lords may wish to join. Mindfulness will allow people to understand that mind and body are one and that we should care for each for the development of the other. Thank you.
Baroness Tyler of Enfield (LD)
My Lords, I want to start by saying why this is such an important debate and thank the noble Lord, Lord Layard, for securing it. Some of the biggest inequalities in health today are faced by people with mental health problems. Nothing illustrates that more starkly than the fact that we know that people affected by serious mental illness die on average 20 years earlier than the rest of the population from preventable physical health conditions—something I am sure we all regard as a scandal. Thus I strongly welcome the Government’s very clear commitment to achieve parity of esteem for mental health. The 2011 strategy document, No Health Without Mental Health, made an unambiguous commitment to parity of esteem and set a clear objective that more people with mental health problems will have good physical health, fewer people with mental health problems will die prematurely, and more people with physical ill health will have better mental health. In addition, of course, as we have heard, the NHS mandate commits to achieving this and will carry out a progress report in 2015.
I think, however, that in this Chamber we would all accept that there is still a long way to go. To make a reality of these very good intentions I contend that three things need to happen. First, people with mental health problems must have the same access to treatment and services as those with physical health problems; secondly, they must have the same rights within the NHS constitution; and thirdly, they must have equal patient voice as those with physical health problems. What more, then, can be done in practice?
I will start with something that I regard as very positive indeed, which we have heard spoken about so eloquently by the noble Lord, Lord Layard. I refer to the Improving Access to Psychological Therapies programme. We all know that in many places this programme has provided an invaluable service. It has achieved high recovery rates and has helped people both get back to work and stay well. Indeed, an IAPT service user recently told the mental health charity Mind that:
“Receiving psychological therapy turned out to be the best thing that could possibly happen for me, it was exactly what I needed … a place for me to finally look at my past and put the pieces together and come to understand why I felt the way I did”.
I shall now talk about how this affects people with complex needs. It was, of course, hoped that focusing additional resources on the more common mental health problems, such as anxiety and depression, would free up waiting lists and resources for other forms of therapy for those with more complex needs, such as people with substance misuse problems and those with more severe mental health problems. As ever, there have been unintended consequences. It is worth emphasising that IAPT was never intended to act as a comprehensive service delivering all forms of psychological therapy. Indeed, Department of Health guidance made it clear that IAPT money should not be used to replace funding for other psychological therapies. Despite that, in 2010 the We need to talk report showed that this was happening in a number of areas, where non-IAPT services were either having their funding cut or being entirely decommissioned, so that IAPT was replacing, not improving, the provision of psychological therapies.
If this were a physical health problem we would not tolerate the lack of choice and treatment options given to people with mental health problems. In some places we are in danger of reaching the point where if you do not get better after a course of CBT there is simply nowhere else for you to go—and we all recognise that for some people, CBT is not the right choice of therapy in the first place. There are other NICE-approved therapeutic interventions that should also be available.
I shall ask the Minister two questions. First, do the Government recognise the need to provide a full choice of evidence-based psychological therapies on a sufficient scale to meet the requirements of people with more complex mental health problems? Secondly—this echoes something that the noble Lord, Lord Layard, said—what plans do the Government have to introduce standards for waiting times for mental health equivalent to those for physical health, and, in particular, to amend the NHS constitution to ensure the availability of psychological therapies within 28 days of a referral?
I now turn to preventive approaches, and in particular to intervening early in a child’s or a young person’s life. There is now clear evidence of the importance of intervening early to promote resilience in young people, to prevent mental illness and to promote well-being. The children with the poorest life chances of all are those who have early-starting behavioural problems. They are 19 times more likely than their peers to be in prison by their mid-20s, and have high rates of school exclusion, unemployment, gang membership—especially among girls—suicide, and a range of physical health problems during their lifetime.
Cost-effective parenting programmes are now available for families whose children have behavioural problems, to help them manage them from an early age. These include family nurse partnerships for the most vulnerable families and parent training programmes. Of course, availability of these programmes is patchy and they are not always delivered as intended for maximum effectiveness.
For parity to extend to children with behavioural problems, two things are necessary. First, maternity services, health visitors, GPs and schools should regularly look out for families at risk and routinely assess healthy child development to identify children with early signs of behavioural problems. Secondly, parenting programmes should be made available to families who really need them, targeted towards those in greatest need but with easy referral routes to prevent them from becoming stigmatised.
I now turn to how primary care and mental health services are configured. I do not think that it will be a surprise if I say that they often do not work well together. How could primary care services be designed so as to encourage better integration with mental health services? There are three potential big improvements. The first would be mental health support for the 4.6 million people in England with major physical conditions, such as diabetes, heart disease and cancer, and a concurrent mental health problem—most likely to be depression—by offering psychological therapies, as I described earlier, and help with self-management. The second would be physical health support for people with severe mental illness—for example, those who may need help with weight management, particularly those on anti-psychotic medication, and with smoking cessation. Finally, there is care for people with medically unexplained symptoms. At least one-quarter of hospital outpatients who have physical symptoms with no explained physical cause may very well benefit from psychological support.
Breaking down the barriers between primary care and mental health is vital to achieve the changes that we want to see. I contend that GPs need clear incentives to address the overlaps between physical and mental health—for example, through the Quality and Outcomes Framework for general practice—and that payment systems for mental and physical healthcare need to be better aligned to prevent mental health budgets being raided when there is pressure on acute hospital spending. On that issue, we hear almost daily of the pressure on A&E departments. There are growing concerns about the quality of care and support that people with mental health problems receive when in crisis. Recently published research showed that people using mental health services were twice as likely as others to present in A&E, causing all the problems that we have heard so much about.
In the comprehensive spending review of June 2013, the Chancellor committed to every A&E department having constant access to mental health professionals to ensure that people with mental health problems got the best possible care. That is something that I very much support. It is vital that all hospitals put in place comprehensive liaison psychiatry services, available 24/7 to all hospital wards for people of all ages, from children with emergency admissions for self-harm to older people with dementia. Can the Minister update us on progress in this area?
I stress the very important and key role that family, friends and the wider community can play in mental health and well-being. In many areas, we have seen good projects and approaches. There is support and care for the families and carers of those with mental health problems, as well as, in some cases, carers having their own recovery plan, which is a very interesting idea. Finally, I emphasise the important role that health and well-being boards should be playing to embrace mental health, seeing it as a key aspect of public health. I know that in local government its profile is being raised, and some local authorities are now having a local authority mental health champion. That is very positive—to have a member who can champion mental health issues in every single area of council business—and I hope that we hear of more such examples today.
Baroness Murphy (CB)
My Lords, the sustained commitment of the noble Lord, Lord Layard, to improving mental health care has had a profound impact on mental health services since 2008, and I admire him for it. If today I challenge some of the priorities, this in no way detracts from his remarkable achievements in addressing the needs of a long-neglected group of patients who, after all, make up the vast majority of a GP’s mental health load. But I return to patients with severe mental illness, including schizophrenia, the recurring psychoses, and those with mixed substance abuse and psychosis. As the noble Baroness, Lady Tyler, said, the importance of achieving parity of access and healthcare for them is shown starkly by the increased mortality and physical morbidity that they suffer. As Professor Graham Thornicroft from the Institute of Psychiatry has memorably observed, patients with long-term psychoses have third-world mortality in a first-world country, dying on average 20 years earlier than the general population, often of preventable smoking-related diseases and treatable cancers as well as the obvious suicides and accidents. This is completely unacceptable in a country such as ours, so I would like to know what are we doing for them and whether we are truly prioritising those greatest in need.
There have been considerable successes in the mental health strategy that has been adopted in recent years, and I mention in particular the increased services for people with dementia, which has undoubtedly risen up the Government’s awareness scale. That has been a great help for families which have a person with dementia. We have also had some success in trying to improve the assessment of risk to others posed by some severely mentally ill patients. This year’s annual report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness by Professor Louis Appleby and his colleagues shows that homicide by mental health patients has fallen substantially since a peak in 2006. The most recent figures are the lowest since data collection began, albeit in a setting of a national reduction in homicides. This is especially true for people with schizophrenia. The homicide statistics are tiny, in spite of what might have been heard on the news in the past week—they are now extremely small—but they are very important as an indicator of the cultural attitude of mental health workers to assessment of risk.
But all is not well. Suicide by mental health patients has risen again. There were more than 1,300 deaths in England in 2011, after a previous fall. The rise partly echoes the rise in suicide in the general population, probably related to the economic downturn, as has happened in every previous recession that we can measure. But in recent years there have been more suicides in those undergoing home treatment or crisis resolution than in-patient care, which used to be one of the areas with the greatest risks. A substantial proportion of these deaths occurred in patients who live alone, have refused treatment, or are accepting only partial treatment. Services simply are not providing enough round-the-clock care of the right kind to the very severely ill. The mantra of home treatment needs better thinking through if we are to keep patients out of hospital and safe.
So we have made substantial gains in some areas but are losing pace in others. I have concerns about the direction that mental health services are now taking. I do not want to disparage the value of treating patients with common mental health episodes with cognitive behavioural therapy and other NICE-recommended therapies, but we have to be aware that the budget for psychological therapies has gone up from £100 million annually to £400 million without even reaching a high proportion of sufferers of the milder forms of distress, as the noble Lord, Lord Layard, has said. I do not dispute the efficacy of such treatment; with good CBT, faithful to the model delivered by a good therapist, 40% get better, of those who accept the offer of treatment, which is 15% better than doing nothing. For mildly to moderately unwell patients it is effective. But we have to recognise that the studies do not include patients who never accept treatment because of chaotic lives, intrusive events, a dislike of sitting down and talking, a failure of faith in the referrer, which is all too often the case, and sometimes also because people have learning disabilities and are unable to value the treatments, in spite of those patients having a very high order of risk of depression and anxiety. These factors significantly reduce the efficacy of treatments. We would surely get better value for money from addressing the problems which still beset people with more serious long-term mental illness. I accept the economic argument from the noble Lord, Lord Layard, for treating lesser forms of disorder; it is very compelling. But the only true justification for treating patients is the overall reduction in patient suffering and the burden of disability overall in the community, which is worse for those with the most severe illness.
The USA introduced a parity of esteem law in 1996. It was meant to improve the investment in mental health services through Medicaid and other insurance and to bring it up to the level of physical health services. I accept that managed care solutions funded by the public purse in the United States are not entirely analogous to publicly funded systems here, but they are similar enough. There is now worrying evidence that, in the States, the greater access to services for the less severely affected has impacted negatively on the care of the seriously mentally ill. A recent study by the well-known sociologists David Mechanic and Donna McAlpine, who for many years have been experts in the United States on the provision of mental health care, demonstrated that this apparent increased democratisation of mental health has simply shifted money from the severely ill to the lesser forms of illness, away from those with the least chance of ever being able to work and those with the highest excess mortality and suicide rates.
These findings are deeply worrying and should give us pause. There is some evidence that this is already happening here. In 2011-12 there was a reduction in spending on crisis resolution and on outreach services for those in acute crisis, while spending on psychological therapies rose by 6%. Total spending on mental health has increased by a massive 60% in real terms over the decade. That is something for us to celebrate, but now we are beginning to see a fall in investment in the acute care end.
It seems to me that the NHS and social care services should listen more to Mind, Rethink and SANE, and listen to what their priorities are. If true parity of esteem is to be promoted then we must look at the way that these acute and crisis services are running. Four in 10 trusts have staffing levels well below established benchmarks. There are serious issues around safety, respect and dignity in in-patient care. There are still insufficient non-hospital options.
As long as 10% of patients with schizophrenia kill themselves, we have not got our priorities right. As long as the rate of psychosis in prisons is 50 times higher than in the general population, then we have not got our funding priorities right. If we are really to make headway with mental health services, we must first and foremost concentrate on those who pose the highest risk to themselves or the highest risk to others, and try to improve the lives of people whose lives are truly blighted by long-term psychotic illnesses.
Lord Alderdice (LD)
My Lords, I also congratulate the noble Lord, Lord Layard, on achieving this substantial debate and indeed, as he himself mentioned, on the timing of the debate. He has been pressing the case for some time, and in doing so he has my support and that of many in this House. I identify myself very much with the speeches of my noble friend Lady Tyler of Enfield and the noble Baroness, Lady Murphy. I wish to touch upon many of the things that they mentioned and I strongly support others, although I will not refer to them.
As was said by the noble Lord, Lord Layard, in many ways this debate comes from the crucial decision by your Lordships’ House to press the case for parity of esteem between physical and mental illness to be included in the Bill which passed through this House. I well remember that reassurances were given, both in negotiations outside the House and on the Floor of the House, that this was not necessary. I pay tribute to my noble friend Lord Howe, who has made it very clear on a number of occasions since the Bill became an Act that it does make a difference, that it is a legal requirement, that health commissioners now have to address this question, and that others who need care can turn to it in various ways as a matter of law in this country. We must now press the case as strongly as we can. I welcome this debate because it is part of the process of pressing the case.
The noble Lord, Lord McColl of Dulwich, reminisced about his experience as a medical student, and inevitably encouraged me to think in the same way. I remember quite a different experience. As a young medical student I went to work for a psychiatrist, Dr Artie Kerr, for a number of weeks. I was enormously impressed by the way in which he could understand what was going on behind the scenes with the patient. He was able to pick up—and to help me to understand in a way that I simply had not seen at all—how sometimes the person who came along smiling was actually deeply depressed inside, and how in fact much could be done even with those people who had been ill for a long time, not least in caring for them when you could not cure them.
What an extraordinary business it is that we think that if you cannot cure someone with a mental illness you should not bother to look after them. If this was a patient with diabetes, which we cannot cure, would we say, “Ah well, we should forget about it”? Take a child with cystic fibrosis. We know that they are likely to die early, but should we say that we should not bother putting any money into caring for them? Yet if someone has a mental illness, and they are not going to get better in a short time or perhaps not at all, then caring does not seem to matter. It is all about cure. Let us not be seduced by those kinds of arguments. They take humanity out of our service, and they take humanity out of ourselves. It was that understanding from Dr Kerr which made me feel that that is the kind of work which I want to pick up on.
As a junior psychiatrist I used to spend a lot of time going round NGOs and charitable bodies, giving lectures and doing radio and television work at home in Northern Ireland, trying to get across this whole question. I remember very well doing a programme with a very senior surgeon, Professor Rodgers. He had been a surgeon all his life, and was a very eminent man. He listened to me for a little while, and then he said, “You know, I have treated many people with terminal illnesses, very painful illnesses, who were having a very hard time. Very, very few of them ever decided to end their life; some did, but very few. But I know that a large percentage of people with mental illness find life so intolerable that they want to bring it to an end. In many ways, the suffering of mental illness is so much greater than the suffering of even some of the dreadful cancers I have had to treat”. I have never forgotten that. It was a very human response, and a very real one.
One of the striking causes of mortality in mental illness is of course when people take their own life, in suicide or in self-harm that goes further. We are talking about something that really does mean a life-threatening disturbance. That is why I was commissioned, with a number of colleagues, by the royal college to produce a report on suicide and self-harm, and what we can do for patients. That report was produced in June 2010, and it was not just a matter of a few of us sitting down and thinking about it. We did a survey of a large number of members of the Royal College of Psychiatrists, and we concluded that,
“there is enough evidence to demonstrate that we are far from achieving the level of care that service users need or the standards set out in policies and guidelines. Poor assessments, relying too much on risk issues, staff unskilled in dealing with patients who harm themselves, inappropriate discharge arrangements, lack of follow-up of patients, lack of care pathways, insufficient access to psychological treatments and poor access to services for particular groups amount to inadequate standards of care that impact on the lives of service users and their families. There is a serious problem relating to the deployment and availability of senior staff, with adequate psychotherapy and psychiatry training. It is likely that because of these services and staffing defects, the majority of self-harm remains invisible until a crisis occurs, adding to human misery and to the stress on hospital services.”
The noble Baroness, Lady Murphy, pointed out that since that time in 2010 the incidence of suicide has actually increased rather than decreased. I therefore ask my noble friend the Minister if he would agree to meet with me and a small number of colleagues from the Royal College of Psychiatrists to look at how far the findings of that report have been taken up and implemented by Her Majesty’s Government since then and how far they have not, and to explore how some more progress might be made on the findings of that report.
While something dramatic such as self-harm or suicide is clearly a crisis, there are all sorts of ways in which mental disturbances differ from each other. This is not a homogenous group of people with a homogenous group of disorders, which is one of the reasons why we run into problems. On the physical side we are very aware of the difference between symptoms and a disorder. If I run up the stairs to the Principal Floor I will probably be breathless; I am not terribly fit, you see. That is a reaction to physical exertion, but it is not a sign of illness. It is a sign of unfitness, but not a sign of illness. However, if I am sitting on the Bench here and I become breathless, that is wholly another matter.
There are many ways in which we experience psychological symptoms. It always seems curious to me that we accept that we will all have physical illnesses, mild and more severe, during our lives, yet we pretend to ourselves that we will not have mental and emotional disturbances—every single one of us, not just the ones who have to be referred for treatment. However, many of the emotional reactions that we have are not a sign of illness or disturbance. If someone is down and depressed and is not sleeping very well three weeks after the death of their spouse, that is not a sign of illness; it is a sign of an appropriate reaction to a bereavement. If, three years later, they are in the same state, that is another matter. However, we have to differentiate those people who can get better with a little help from their family and friends and whose condition does not need to be medicalised, as well as those who suffer from relatively moderate disorders, from those who have very severe disorders, as the noble Baroness, Lady Murphy, pointed out. It is clear that if we do not do that, we will be so swamped that it will be impossible to deal with the problems. What will happen is that those with the more severe illnesses will end up being set to the side because they have illnesses from which it is difficult to get better. That is a very serious problem for us.
I should like to believe that we have begun to think not only about treating the illnesses but about how to prevent them. We are clear that government policy should say that we should not smoke, drink too much or eat too much and that obesity needs to be addressed. However, what about bullying behaviour in government departments? It sometimes almost seemed to be a policy approach that the way to increase productivity was to drive people into the ground, and I have absolutely no doubt about the adverse mental health impacts of that. Surely preventive health plays a part in the way that we approach things in government and set as an example to people outside government.
Worst of all is the feeling that somehow things are getting worse—that we are taking less of an interest in certain areas. I shall give your Lordships one example and, from that, pose a question to my noble friend. In the early 1960s, a chair of mental health was created at Queen’s University in Belfast. For the next 30 or more years, psychiatry and mental health was developed as a crucial component of the training of young doctors in Belfast. There is now no professor of psychiatry or mental health in Belfast. Massive amounts of money go into cancer research but there is not even a professor of mental health. Will my noble friend approach the GMC and ask it to insist that no medical faculty trains young doctors without having a professor of psychiatry in its medical faculty? It seems a very simple thing to ask.
Lord Adebowale (CB)
I start by thanking the noble Lord, Lord Layard, and the noble Earl, Lord Howe, for bringing forward this debate on what is a vital issue not only for our health and social care systems but for society more widely. I should declare my interest as the chief executive of a health and social organisation called Turning Point, and I will draw on some cases that Turning Point has come across to illustrate why parity of esteem is so important. I should also declare my interest as a non-executive director of NHS England. Many of the points made by other speakers, including the noble Lords, Lord Layard, Lord Alderdice and Lord Stone, and the noble Baroness, Lady Murphy, I take to heart, and they can be assured that I will be making those points around the table of NHS England.
The strategy, No Health Without Mental Health, and the subsequent implementation framework make it clear that mental health is everyone’s business: one in four adults and one in 10 children in the UK are experiencing mental health issues at any given time; 30% of the 15 million people with a long-term health condition also have mental health problems; and, as has been pointed out by the noble Baroness, Lady Murphy, within a prison environment up to 90% of the population experience one or more mental health conditions, often alongside substance misuse and/or a learning disability. Given this and the costs of mental health, calculated by the Centre for Mental Health to be £105 billion, it is frankly shocking that huge disparity still exists between those with a diagnosable mental health issue and those without. As has already been mentioned in the debate, this results in there being an unacceptable difference in the life expectancy of those with a severe mental health condition and those without of between 16 and 25 years.
I want to illustrate my contribution to this debate from the perspective of people who have mental health issues, and perhaps I may do so by presenting to the House three very short vignettes. The first is a case that has come to the attention of Turning Point. It illustrates a lack of consideration of an individual’s whole needs. It concerns a chap called Fred, although I have changed his name. He has a learning disability and a history of poor eyesight, which staff assessed as contributing towards his high levels of anxiety. Staff working closely with Fred arranged for him to access specialist optical services. It was found that he had a detached retina and cataracts were diagnosed, leading to surgery. Following this surgery, a decrease in what had been perceived as “challenging behaviour” was clearly evidenced. This is someone who, because of a physical illness, had been classed as severely problematic.
The second case concerns professionals failing to work together. Alan had enduring mental health issues when he experienced a stroke and was admitted to the local hospital from one of our residential services. While in hospital undergoing rehabilitation, Alan had all medication reviewed by a ward doctor. The doctor, knowing that Alan had a mental health condition, decided without any discussion with him, the care manager or psychiatrist to stop his medication, even though it had a multiple purpose. It could be used to reduce mood swings and also to treat epilepsy. The hospital doctor stated that, as Alan did not have epilepsy, the medication could be stopped with immediate effect. This had a detrimental effect on his mental health—something that the doctor appeared to be ambivalent about, having not once discussed anything other than Alan’s physical needs with any member of his care team.
The final case is, I think, the most shocking example and most immediate in case we have any doubt that these issues are taking place right now. It involves a support worker who just happened to be at the bedside of one of our clients. They noticed that the file was open and that there was a “Do Not Resuscitate” note in it. Luckily, the care worker knew that no such thing had been discussed with the individual’s next of kin. The support worker challenged hospital staff and was told that because the individual was a mental health patient and under a Home Office order, he had “no priority of life”. Because our member of staff challenged this, the DNR note was removed, but the fact that it was there in the first place highlights the discriminatory treatment that people with a mental health condition can face, which is compounded when other complex needs are applicable, such as offending behaviours or a learning disability.
The implications of introducing parity of esteem are wide-ranging and they highlight the vast amount of work still required to make it real. Rhetoric, commitments and case studies have highlighted the need for parity but there are certain things that have to happen if this is to be embedded throughout the health and care system.
We will simply not achieve parity of esteem without first addressing equality of access and experience. This means breaking down the cultural barriers that still prohibit people from black and minority ethnic communities receiving the support that they need. As the Mental Health Foundation has found, people from BME groups are more likely to be diagnosed with mental health problems, more likely to be diagnosed and admitted to hospital, more likely to experience a poor outcome from treatment—this has been repeated in annual surveys of people in mental health institutions —and more likely to disengage from mainstream mental health services, leading to social exclusion and a deterioration in their mental health.
Staff at all levels of the health system, including GPs and A&E staff, must receive adequate training in mental health. So, too, should the police—something that was brought very much into my experience when I chaired the Commission on Mental Health and Policing. The police are too often the first point of contact for people experiencing a mental health crisis.
The commission reported that one of the clearest examples of disparity between physical and mental health was in regard to how the police and ambulance service respond to a crisis. If I or one of your Lordships had a heart attack—heaven forfend—I can guarantee that an ambulance would arrive within eight minutes. If I had a mental health crisis, it is more likely that I would be carted away by the police and it is highly likely that I would be put in the back of a police van. Such disparity has led to the deaths of too many people, particularly from BME groups. Responding to crisis is a whole other debate but, for me, it is the very start of any definition of parity of esteem. If you cannot have parity of esteem when you are in crisis, when can you have it?
Finally, I turn to something that I spoke about a lot when the Health and Social Care Bill was going through the House: the issue of integration. Until we have a health and care system that looks at the whole person and designs, commissions and delivers services in conjunction with the community to ensure that they are fit for purpose, fragmentation will persist. People will continue to receive disjointed care where their mental health issue is not considered alongside their physical health condition because it is not a priority or is not understood well enough.
The implications of embedding parity certainly will be challenging and require people to work differently, but if we do what we have always done, we will get what we have always got, and the experiences of the people that I have highlighted show why this is no longer acceptable.
Baroness Warwick of Undercliffe (Lab)
My Lords, I thank my noble friend Lord Layard for providing this opportunity on World Mental Health Day to focus our attention on how we treat mental health in our National Health Service.
The prevalence of mental illness in the UK was starkly set out in the Government’s mental health strategy, No Health Without Mental Health. I have no expertise in this area, but the figures are desperately worrying. Others have mentioned them, so I will just single out three: almost half of all adults will experience at least one episode of depression during their lifetime, and depression affects one in five older people; about 10% of children have a mental health problem at any one time; the UK has one of the highest rates for self-harming in Europe—400 per 100,000 population. Perhaps I should add that only one in 10 prisoners has no mental disorder.
These numbers have far-reaching impact. As we have been reminded, people with severe mental illnesses die on average 20 years earlier than the general population. People with mental health problems often have fewer qualifications, find it harder to find and stay in work, are more likely to be homeless and have poor physical health. We know that higher levels of insecurity and stress due to the recession, the poor job market and major upheavals in the welfare system have all had an impact on the mental health of the nation in recent years. It is no wonder that mental health services—what my right honourable friend the leader of the Opposition recently called the “afterthought” of the NHS—are straining at the seams.
As others have noted, mental illness is responsible for the largest proportion of the disease burden in the UK at 22.8%, larger than cardiovascular disease at 16.2% and cancer at 15.9%. Yet only 11% of the NHS budget was spent on NHS services to treat mental health problems for all ages during 2010-11. While figures show that investment in mental health services for adults of working age has increased by 1.2% in cash terms, this in fact amounts to a real-terms decrease.
My noble friends Lord Layard and Lord Stone drew attention to the poverty of investment in research into mental health issues, on which I hope that the Minister will comment in his reply.
A report last month from the Mental Health Foundation, Starting Today, showed how demand is rising just as investment in mental health services is falling. It reminds us that these services face even greater pressures in the future: a growing and aging population, increasing levels of simultaneous mental and physical health problems and, of course, funding constraints that have no end in sight. One of its key findings was the need for mental health to be treated as a core public health issue, with a public health workforce that sees mental health as one of its core responsibilities so that,
“it will be as normal for everyone to look after their mental health as it is to look after their physical health”.
This finding is at the heart of today’s debate. I support the Mental Health Foundation in its call on the coalition Government to prioritise investment in our nation’s mental health services. There is an overwhelming need for the aims of parity of esteem to be speeded up and given even higher priority.
The MHF report generated some useful media coverage. However, I am afraid that many more people will have read the stories just days later about the appalling “mental patient” and “psycho ward” Halloween costumes briefly released by two supermarkets, Tesco and Asda, offering customers the chance to dress up as a terrifying, straitjacketed crazy person covered in blood and brandishing a meat cleaver, or in an orange boiler suit, complete with jaw restraint and optional machete. The retailers withdrew the products and apologised with donations to the charity, Mind.
However, then came this week’s front-page headline in a tabloid newspaper, the Sun, giving a shock figure about the numbers “killed by mental patients” over the past decade. The headline plays on precisely the kind of prejudice that people with mental health problems have come to fear most, implying that they are violent, unstable monsters. Of course, the reality is that people with mental illnesses are three times more likely to be victims of crime than the general population, they are five times more likely to be victims of assault and severely mentally ill women are 10 times more likely to be assaulted.
Appallingly, victims say that their reports to the police are often dismissed or disbelieved. So it was good to see, earlier this summer, that there is to be an extension of the pilot scheme for mental health nurses to accompany police officers on emergency calls, to try to improve the way that people with mental health problems are treated during emergencies. This might go some way to avoiding incidents such as those referred to by the noble Lord, Lord Adebowale, and one that a friend of mine recently reported to me. A colleague of hers had a husband who was finding it difficult to manage his bipolar medication. He had gone missing during a particularly distressing bipolar episode and the wife’s sister, a GP, had alerted the local police about his condition. Nevertheless, when he was found, banging on the locked door of a church, he was handcuffed, mistreated and kept in a police cell overnight on the assumption that he was drunk and would be sober in the morning.
We must tackle the stigma attached to mental illness. That stigma feeds prejudice and can lead to discrimination, particularly at work. For me, this comes close to home. A senior member of my staff told me only years later that she had left out her own brief history of clinical depression on the HR department’s health declaration form, for fear of being considered not capable of doing the job. That fear of discrimination remains. As someone told me recently, “If you phone work saying you’re staying in bed for a few days with flu, employers will be understanding. You’re not likely to get the same response if you say you’re staying in bed because you’re depressed, or feeling suicidal”.
Stigma and discrimination ruin lives and prevent people with mental health problems using their full potential and playing an active part in society. Mind and Rethink Mental Illness are campaigning to change this, but, sadly, it is still true that we view mental illness differently from physical illness and that has a direct, negative impact on people with mental illness and on the understanding and services that they receive.
The Mental Health Network says that parity of esteem for mental health will happen only if services and organisations work together. The Royal College of Psychiatrists’ trenchant Whole-Person Care report earlier this year sets out what it believes a parity approach should look like. Crucially, it emphasises that there should be investment in the prevention of mental health problems and in the promotion of mental well-being, in proportion to need. Yet only five strategic health authority regions were able to report increased investment in mental health in 2011-12. Underinvestment in the mental health care system, when those in most need often miss out on essential care, is a disgrace. While we have heard much about the Government’s commitment to ensuring parity between services for physical and mental illness, it is abundantly clear that we need to do much more to bring this parity about. There used to be a taboo about speaking about cancer —“the big C”—as which, thankfully, has now disappeared. The same must happen with mental illness.
To end, I will echo the concerns of my noble friend Lord Layard about the new commissioning systems. Will the Minister, in his reply, tell us how the new GP commissioning process, as a front-line service, will respond to the need for parity? How will CCGs be helped to improve their mental health commissioning capability and the quality of the mental health services that they are commissioning? What assurance can he give us that the new NHS commissioning systems will truly deliver for mental health?
Baroness O'Neill of Bengarve (CB)
My Lords, I think that we are all very grateful to the noble Lord, Lord Layard, for securing this debate. It is a theme of such enormous dimensions that it is almost tempting to avoid how centrally serious it is. He has concentrated on this area for many years, and I am sure that many of us have learnt from his work. I declare an interest as chair of the Equality and Human Rights Commission, which has among its responsibilities helping to reduce—of course, one hopes, to eliminate—unlawful discrimination on the basis of disability, including unlawful discrimination on the basis of mental health disability.
Speaking in June this year, the Minister with responsibility for care services, Norman Lamb, commented on the Royal College of Psychiatrists’ report, to which reference has been repeatedly been made, Whole-Person Care: From Rhetoric to Reality (Achieving Parity Between Mental and Physical Health). He said:
“What do we mean by parity of esteem? … I think the report—in its definition and vision for parity—has it right. It’s about equality in how we think about mental health and physical health care—it’s about how they’re valued. We need to ‘close the gap’ with physical health services—whether that’s a gap in access, in quality, in research, or even in the aspirations we have for people”.
As the Minister made very clear, this is an extremely large agenda ranging from the commissioning of services and the integration of services to interventions to reduce premature mortality among those suffering from mental health conditions. It is also an agenda that stretches far beyond the NHS. Indeed, it is an agenda to which anybody and everybody, particularly employers, communities and schools, can make a large contribution.
Parity of esteem is not just a matter of ensuring that different conditions are treated with the expertise appropriate to them, although that is, of course, central. It is not just a matter of concern within the health and care systems that the people who suffer these conditions are treated with dignity and respect. It extends far beyond medical treatment and care, and many non-medical approaches are also of great importance.
First, I shall give a brief reminder of how stark and bitter the absence of parity of esteem and all that goes with it can be for those who suffer mental health conditions and for their friends and family. I have been permitted by a colleague to quote from an account from a family with two sons who are both young adults. One is in an advanced stage of muscular dystrophy and the other is diagnosed as chronically mentally ill. The family said:
“The son who is physically disabled has many special needs. He gets emotional support everywhere he turns. His handicap is visible and obvious and the community, family and friends open their hearts to him and go out of their way to make his life better. My other son, on the other hand, is misunderstood and shunned by all. He is also terribly disabled … but his disability is not visible.”
At least, it is not visible in the same way. The extended family,
“all think that he’s lazy, stupid, weird and naughty. They suggest that somehow we have made some terrible mistake in his upbringing. When they call on the phone they ask how his brother is and talk to his brother but they never inquire about him. He upsets them. They … wish that he’d go away”.
That is poignant and sad, and shows how stark the absence of parity of esteem and all that goes with it can be for those who suffer mental health conditions. That probably is an extreme case, all the more poignant for being in one family, but it reminds us of a lot.
Of course, these conditions and their diagnoses are complex and highly varied. Many conditions have both mental and physical aspects. For example—I know that this also is a very large area of need—difficulties with communication are not easily classified as mental or physical, and there are many other conditions that combine both sorts of symptom. We have to agree that there are physical conditions—for example, disfigurement —where sufferers may encounter reactions from others that are as harsh as those sometimes faced by people with mental health conditions.
We also have to remember that there are many conditions which people do not want to disclose. We have very little idea how many of those we live among may be coping on a daily basis with physical and mental conditions that are invisible to us, that they manage more or less adequately and that they try to keep to themselves, be it diabetes or depression, digestive problems or severe phobias. Nor do we have much idea how much physical or mental pain, or both, others are often managing, whether day-in, day-out or episodically. Much of the burden of disease is invisible to others, and much of it is not solely mental or solely physical.
We also must not forget the cases where the conditions are all too visible. One of the difficulties is that the person who has the condition becomes invisible because people focus on the wrong thing. One only has to witness the many terrible stories of the condescension to which wheelchair users are subject, as though the use of a wheelchair somehow rendered one incapable of speaking.
For all those reasons, I believe that, while changes in the way in which we organise health and social care are essential for securing parity of esteem for persons with different sorts of health conditions, much also depends on the social and economic arrangements that we have, and in making sure that they recognise and include those with varying health conditions.
I shall make just a few illustrative comments on the way in which wider employment and community arrangements can make a difference. Let me start with something that perhaps is mainly a concern of schools; namely, speech and language difficulties. It has long been recognised that this is a major area in which complex interventions and social support matter greatly. The Bercow report, A Review of Services for Children and Young People (0-19) with Speech, Language and Communication Needs, was published a few years ago but its findings bear repetition. It states:
“Approximately 7% of five year olds entering school in England—nearly 40,000 children in 2007—have significant difficulties with speech and/or language. These children are likely to need specialist and/or targeted intervention at key points in their development. Approximately 1% of five year olds … more than 5,500 children in 2007—have … severe and complex”,
difficulties in this area.
“They may not understand much of what is said to them … may have very little spoken language”,
and are at risk of other mental health conditions.
Specialist intervention is, of course, what is important for such children and young people but again it is not all that is needed. For those with communication difficulties, the reaction of others can be one of the worst hurdles. The parents of such children,
“expressed concern that their children’s ability to communicate, to speak and to understand was taken for granted”.
They said that,
“their children often looked like any ‘normal’ child and yet behaved differently”.
One parent commented:
“They don’t think quickly and they can’t express themselves quickly, but they look as if they can manage. All my children stare at people because they are looking for cues, and that causes fights”.
Here we can see very clearly that a great deal of what matters for partly invisible conditions is inclusion; that is, including the child with communication difficulties in activities, in school, in play, in the community and, later, in the workplace.
A final example is one that employers can foster. I believe that the example of really energetic ways to develop flexible working can make a great difference to many people. The British Telecom report, Flexible Working: Can Your Company Compete Without It?, states:
“At BT, flexible working is business as usual. Already seven out of 10 people work flexibly and nearly 10% are home-based. It has saved the company millions in terms of increased productivity and cut costs. It has also motivated our people and released more potential … we are attempting nothing less than the complete transformation of the way in which the company runs, the way we communicate, and the way we work together”.
For BT, that saves costs and improves productivity. I think that we must all acknowledge that it is in an advantageous position because telecommunications allows for distant working more easily, but remote working, even if harder in other areas, can have many benefits—above all, the benefit of the possibility of including many people who either could not travel to work or could not work as many hours as some others. It has great benefits for carers, including the benefit of a working life of self-respect and money they have earned.
There are many other examples of businesses making creative and effective use of specific disabilities, including mental health disabilities. There are companies that have found ways to use the distinctive capacities of some people with high functioning autism spectrum disorders to carry out tasks that require focused accuracy and have given them preferential employment in these areas. For example, the Danish company—I may mispronounce it—Specialisterne, is almost entirely staffed by people with autism spectrum disorders. They specialise in the high precision task of quality checking software. Apparently, those of us who do not have those disorders would be less good at it.
The benefits of inclusion matter greatly for those with mental conditions as well as those with physical conditions. We should make efforts to secure as much inclusion in schools, at work and in community life for those with disabilities of all sorts as we possibly can.
Lord Carlile of Berriew (LD)
My Lords, the noble Lord, Lord Layard, has taken a long and influential interest in mental health; not least as a leading economist, he has made a powerful economic case for parity of esteem. We are very grateful to him for securing this debate.
I notice that the noble Lord is sitting alongside the noble Lord, Lord Bragg, on what I suppose one could describe as the polymath Bench this afternoon. This morning, the noble Lord, Lord Bragg, presented a most interesting Radio 4 programme featuring the life of Galen, the extraordinary second century Roman doctor. Galen discovered many things about medicine. One was that he realised that much of the variation in physical health and in human behaviour can be explained by temperament and stress, as he put it. He identified the inseparable links between physical pathology and psychopathology 1,900 years ago. To some people suffering from mental illness in this country and in particular to those who live with them, it can sometimes appear as though little more has been learnt in the past 2,000 years.
Of course, that is unfair. Generally speaking, huge advances have been made in the treatment of mental illness. Drugs are available which, for example, have vastly improved the quality of life for patients suffering from bipolar disorder and, more recently, for patients suffering from acute schizophrenia and other conditions. Therapies, not always involving drugs, have had a remarkable and beneficial impact on many individuals—albeit, I am afraid, with patchy availability in this country. I had the privilege of serving as Member of Parliament for a constituency in rural mid-Wales for some years. This is a bit historic, but even today I understand that the availability of therapies is very uneven in an area like that. You can get a therapy, but not necessarily the right therapy. Providing the correct therapy is extremely important.
The stigma of mental illness remains an obstacle to progress. The fear of telling an employer of a psychiatric diagnosis remains much greater than revealing a physical illness, however serious. In my own legal profession, I have seen careers destroyed by a psychiatric illness of limited duration, whereas a physical illness of similar duration has been received with sympathy and patience and people have been able to return to practice.
There has been some progress. The media have taken a commendable lead. I do not only listen to the noble Lord, Lord Bragg, on the radio; sometimes I watch television drama. Storylines in recent crime noir series, in “Homeland” and elsewhere, have highlighted that anyone, including the at least apparently heroic, can suffer from a mental illness and still lead a perfectly normal life and provide service to society.
Recently, I enjoyed the privilege of co-chairing with Professor Dinesh Bhugra an investigation for the Mental Health Foundation into the future of mental health services. Our report, Starting Today, was produced last month. There is not enough time in a debate such as this to go into the detail of the report, but one of its foundations was pleasure at the 2011 English mental health strategy, which rightly committed this country to parity of esteem. However, the declaration, welcome as it is, has not been matched by progress, which has been variable and not yet quick.
The Mental Health Foundation report has headlined a number of issues which could develop parity of esteem in the coming years. I will refer to a few of them. We certainly took the view that we need to look at fresh ways of implementing known best practice alongside developing technology. Above all, I would like to highlight mental health in primary care. GPs should become—but in only a few cases have become—leaders in mental health care, providing quickly accessible services in their surgeries.
I referred earlier to rural mid-Wales. I know of one practice which years ago introduced a psychotherapist into the health centre in a small Welsh market town. It had a remarkable effect. It meant that the doctor could say to the patient, “I think you need to go down the corridor and talk to my colleague”. An intervention was made which beneficially affected the life of the patient concerned. We need to see more of that. By the way, a two-week wait for an appointment with a doctor just will not do for someone suffering from a growing mental condition. GPs need to know as much about mental illness as about physical illness. So far as possible, primary and secondary mental health services should merge to produce early treatment and the value for money that the noble Lord, Lord Layard, has identified in some of the work he has done over the years on mental health.
The Mental Health Foundation report also found that there is value in self-management. So far as possible, patients in a personalised service should be encouraged to take training in the management of their own care in partnership with therapists and clinicians. A stake in your own recovery is a real incentive for a person who is suffering from mental health problems, but it needs some formal help.
Turning to crisis care and community support, every accident and emergency facility should be equipped to deal with emergency mental health issues, to be followed up by community support. They are not. All over the country, they are not equipped. That is not acceptable.
On collaborative working, I emphasise something that I have encountered in other areas, such as child safeguarding, which is the sharing of information. When somebody with a mental illness goes into an accident and emergency department, a solicitor’s office, a police station or a school, they go into a silo. That is not acceptable. Data protection is used as an excuse for not sharing information. Actually, it is near criminal not to share information for people who have needs that are demonstrated by mental illness. We must ensure that those who have information to share do not sit in silos and that the ability to pool funds from different funding streams into a single integrated care budget, shared protocols and partnership agreements, co-location of services, multi-disciplinary teams and liaison services becomes a reality.
The Mental Health Foundation report also emphasised the beginning and the end of life as key areas where mental health interventions should be made available quickly and fully. Early interventions in schools can identify mental health issues that affect not only the child but the child’s parents and carers. Many cases have been highlighted in some terrible reports that have been produced after fatal events that show that to be the case.
The final issue that I want to raise in the time available concerns the elderly. Perhaps this is an issue that we can raise comfortably in your Lordships’ House because so many of us are OAPs these days. There is a growing issue, as we all know, about elderly care. Many of us have enjoyed having parents who lived into their late 90s and indeed, happily, there are Members of this House in their late 90s, but we know that this issue needs a great deal more work than it has received. It will enable elderly people to lead a full life albeit while suffering from some incipient dementia.
There are many challenges and this debate highlights them. It allows us to show Parliament’s determination that parity of esteem should be a must and not merely a phrase.
Baroness Hollins (CB)
My Lords,
“No health without mental health”,
was the strap line adopted by the Royal College of Psychiatrists during my presidency and now for the Government’s mental health strategy. Dividing a person’s health into either physical or mental is a false dichotomy and one that has for too long encouraged us to focus on parts of a person rather than on that person as a whole. I remember as a medical student being asked to, “See the spleen in bed six”. Things have moved on a little since then, but psychiatric patients still find themselves being referred to as schizophrenics or manic depressives.
Parity of esteem is not, of course, a new concept. As long ago as 1946, the World Health Organisation defined health as,
“a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.
Some 67 years later, billions of pounds in resources have been poured into physical health. We have created sophisticated cancer drugs, mapped the human genome and surgery can be done through tiny incisions. We do not even think of these things as remarkable any more. But the unequal allocation of funding and resources has left mental health some way behind physical health. Parity is not just about increasing resources for those with serious mental illness, but about attending to the physical health of people with mental illness or people with learning disabilities and attending to the mental health of people with physical illnesses.
As an example, GPs receive a payment for offering a health check to people with learning disabilities each year, but although this has been policy for some time, less than 50% of people with learning disabilities have yet had one—no wonder their life expectancy is so much lower than others when the reactive approach to physical health and mental health does not take account of the extra needs of some members of society in order to achieve good health. I would welcome a comment from the Minister about this point.
Parity is something that most people have not even started to think about. The BMA Board of Science, which I chair, is preparing a report on parity of esteem for its members at the moment. But as a colleague at the BMA recently commented, giving parity to mental health is a massive paradigm shift, which will have huge effects for many years to come. Despite the Equality Act, few healthcare staff understand that it applies to disabled people, including those with mental disorders, who are using mainstream health services. Sadly, discrimination is too often alive and well with respect to mental illness and learning disability.
Parity will have an effect on the training and education of all healthcare staff. It will have an effect on the commissioning and organisation of whole person healthcare. Just think: the time may have come to employ psychiatrists in acute hospitals, not just as part of liaison teams, but on the same terms and in the same numbers as other consultants so that more timely assessments and treatments can be offered. There could be psychiatrists who work with children, women, pregnant mothers, older people and adults, working alongside paediatricians, obstetricians, physicians, in the accident and emergency department and so on.
To focus so many of our resources on merely one aspect of health not only leaves other aspects untreated, it makes it difficult to treat physical illness properly. To use an analogy, it is like a three-legged stool, which supports the physical, mental and social health of a well-functioning human being. To take any one of those legs away or to shorten one leg is to leave the stool unbalanced and potentially unable to stand up at all.
I have spent most of my working life in the field of learning disability, both as a psychiatrist and as a parent, and I have often said that if you get it right for people with a learning disability, you will get it right for everyone. People with learning disabilities have complex needs and the interplay and overlap between physical and mental health is inescapable in this patient group. Not only that, but people with learning disabilities have higher levels of both physical and mental health needs than the general population. For example, they are twice as likely to suffer from depression and three times as likely to suffer from schizophrenia. The life expectancy of someone with a learning disability is 20 years less than the general population, even when factors directly related to the learning disability are removed. One in five people with a learning disability will not see their 50th birthday, and half of all people with a learning disability will die from pneumonia, often caused by choking on the wrong type of food or drink or aspirating it and getting pneumonia as a consequence.
This health inequality is often caused by a failure to consider both physical and mental causes of a deterioration in functioning, or to attribute any difficulties to the underlying learning disability—a type of diagnostic overshadowing in that it must be due to the learning disability. The health needs of this group are significant, but if you get it right for them, you get it right for others too.
Take, for example, John. John was admitted to hospital for an investigation of his physical deterioration, but in order to investigate the problems fully, he needed some investigations, some of them uncomfortable, unpleasant or painful. The staff made an attempt to get John to comply, but they were busy and did not know what to do. They shouted at him, begged him, offered him chocolate and called the consultant, but they did not make effective reasonable adjustments to facilitate his care. They did not understand his particular needs. After two weeks, John had had no investigations and his bed was needed, so he was sent home.
Once back at home, John remained listless, tired and kept losing weight. His worried carers eventually persuaded John to go to his GP where he was diagnosed with depression. He took anti-depressives but, crucially, was also given the time to talk about the things that were worrying him. That is unusual, because few psychological therapists have developed the skills to adapt their treatment to meet the individual communication needs of people with learning disabilities or autism.
The second time he went into hospital, because he continued to deteriorate, John had a hospital passport. This is an innovative idea to give hospital staff some guidance about his particular needs. He also had an understanding of what to expect and his depression had been treated. This time he had a successful hospital admission. He was diagnosed with cancer of the bowel, fortunately quite early. He was operated on and has made a successful recovery.
I do not just tell noble Lords that as a story with a happy ending—it could so easily have been different. The importance of this story is that you absolutely cannot adequately treat someone's physical illness without an understanding of that person as a whole. People with a learning disability are often unable to tell us in words about what is wrong and that is why we need to be alert to all the reasons why someone may be ill. But if we get that right, how much easier it will be to remember to ask other people about themselves as a whole.
Failures such as Winterbourne View and Mid Staffs happened because people were not seen as whole people. No one took the time to find out what the problem really was or how to fix it. In the case of Winterbourne View, it was so much easier to send people away to some specialist service than to really think about what was wrong.
You would not build a stool with only one leg and you absolutely cannot build an effective, equitable health system by focusing just on one aspect of health—by not giving parity of esteem to mental health. I have one word of caution. Our mental health is not all down to good assessment and good treatment. Prevention, and mentally healthy lifestyles, are key. That is why cross-government initiatives that recognise the relationship between, for example, poverty, unemployment and mental illness, are important.
In congratulating the noble Lord, Lord Layard, on securing this debate, which manages to coincide with World Mental Health Day, and for his sustained commitment to mental health, I would like to add my support to his suggestion that a senior Minister for mental health be appointed to work across all relevant departments. This is not just a matter for the Department of Health. Will our Government’s foresight in committing to achieve parity of esteem be demonstrable in our international policy and influence as well?
Finally, I hope that the Minister will agree with me that DfID really could help to influence attitudes internationally. There are estimates that 20% of the world’s population will be seriously depressed by 2020; yet only 1% of aid budgets has been committed to mental health services. Can that be right?
Lord Bragg (Lab)
My Lords, I, too, thank my noble friend Lord Layard for securing this important debate and for his comprehensive and definitive speech, one of many erudite and moving contributions. Mental health—or, rather, its opposite—is a subject that impinged on me personally and crucially, some years ago. It was partly for that reason that I joined Mind and eventually became its president for 15 years. I handed over to Stephen Fry a year or so ago. I have talked to my friend, Paul Farmer, Mind’s chief executive, about this debate.
The bleak statistics have been set out clearly by many of your Lordships. The list of lacks is long. Six million adults suffer from different forms of depression; the cost of poor treatment is pain, distress and, we are told, £60 billion. As we have heard eloquently and graphically today, the injustice is intolerable, the neglect is shameful and the effects are often disastrous and on many levels.
The cleverness of this proposal, in my view, lies in the phrase “parity of esteem”. That is key; it opens up several doors, some of which lead to better prospects than others. We all agree that this parity must be based on parity of treatment with physical illness, as has been well said again and again. Progress depends on investment, but it also depends on something just as important, which is a fundamental change of attitude and the will to bring it about. The ancient stigma is dissolving, but very slowly, and is still, I suggest, however unconsciously, the major impediment to the parity that my noble friend Lord Layard seeks.
In terms of investment there is a deep problem; perhaps that is the elephant in the Chamber. We have an outstandingly good health service. I experienced it recently through myself, my family and two of my friends over the past 18 months, in the north-west of England, in Edinburgh and here in London. In every case we met high skills, courtesy and care—and still free, as Bevan intended. It is an amazing asset and a flagship for this country’s decency.
Today, however, this is accompanied in general terms by a rarely and uneasily articulated, yet growing, fear that this noble ideal—this vow in our country to deliver such a service, from however difficult a childbirth to however lingering a death—is now under serious threat, failing, falling and going. The extensive and inclusive nature of our health service is both its greatness and, in some people’s view, is proving to be its weakness. From the latest intricate and expensive surgery to looking after dumb Saturday night drunks; from the increasing flood of the complex ailments of old age to cosmetic surgery; and from dialysis to a small bruise, it serves a multiplying range of complaints and demands. As the needs increase, can we continue to afford it? Do Governments want to afford it? We read about subtraction, but rarely about additions: cutting is the sound of the day.
In that context I suggest that at present, sadly, mental health is low down on the list of priorities. It is a very demanding aspect of national health and of the utmost concern to all of us here, as it should be to everyone in the country. All of us here are trying to improve the position of those afflicted, at whatever level. Although we must keep up the pressure, it seems that we cannot merely reach out to the Treasury. We have to find other ways, if only as interim measures.
The direction to which my noble friend Lord Layard points us is as much in the human as in the economic sphere. Mind’s steady encouragement of people in the public eye to admit to mental health problems is one useful method. I did so myself when I became president of Mind 17 years ago; the public reaction was one of overwhelming relief. “I found that I was not alone”, people said, again and again. Too many people still are alone.
Next to increased investment, one of the best ways to meet this challenge is to find parity in the workplace, which gives people esteem in the eyes of others and of themselves. The knock-on effects are extremely encouraging. This has already been tried and encouraged by Mind. I will give one example. As part of Mind’s employee support programme, EDF offered psychological support—cognitive behavioural therapy—to employees and trained more than a thousand managers to recognise mental health problems among staff and develop support strategies. Job satisfaction has already, over a couple of years, risen from 36% to 68%. There also have been marked savings through increased productivity and increased profits. All this is a reason for some optimism this afternoon.
This programme could be developed further and would benefit from a higher profile. Does the Civil Service, do local authorities and do we here in Parliament take on and help people in the workplace with mental health problems in that way? Could we introduce legislation to move that along? It could help, and would be widely welcomed as a positive move; it could set an example. Could we not find a way to develop that?
In short, we need more money, more understanding and more resources. However, we also need more attempts to integrate people into the workforce and to educate those more privileged in health to understand and throw out a new lifeline. Parity of esteem might come most surely of all from friends at work and the respect gained by working with other people. I believe that many people in this country are ready to support that.
Lord Addington (LD)
My Lords, this is one of those debates in which, having put down your name to speak, by halfway through you are convinced that you do not have much to contribute. However, the main thing that attracted me to the debate in the first place was that it concerned parity of esteem between mental health and physical health. It has always struck me that the two are absolutely inseparable: you cannot remove one from the other. This is not just about the healthy mind and the healthy body; it is about the fact that you cannot access either one without paying attention to the other.
As has already been said in the debate, we had the problem that mental health was something that happened to other people and thus was something that did not concern us. We removed ourselves from it as a society. It is only over a comparatively recent time that we have started to realise that it is a mainstream problem. The similarities between that and some of the work I have done in other fields—for instance, on hidden disabilities, particularly dyslexia—are many. If what I do is normal or what I perceive to be normal, everything else will not be addressed. There are two things going on: the perception that it is nothing to do with me—I do not understand it, and I do not want to understand it because it is unpleasant—and the idea, as has been referred to in the debate, that we all know exactly what the mentally ill are like. They are basically people running around with meat cleavers and chasing around or shrieking at people on buses; they are not people who are in a state of depression. I almost said “unhappiness”, but it is being depressed, or functioning below par. Perhaps it is making the lives of those around them unpleasant; not fulfilling their greatest function; not interacting with family members. With depression, the field is far too wide to cover everything. That person is more than likely to be the standard person who has a mental health problem; he is not somebody who is in any way dramatic. That person is also going to be very bad at getting over the fact that he is ill and suffering from a long-term condition. As has been mentioned before, the life expectancy of those with mental illness is considerably lower than those without it.
So how do we get into this? Part of the work, clearly, has already been done by the noble Lord, Lord Bragg, who started off by saying that this is not that unusual, please open your minds to the possibility that this could be a very normal part of life. Furthermore, the rest of us will have to work a little harder, first, to take on new ideas and, secondly, to access the potential of those people to get the best out of it for us—the economy and the selfish principle within it. If those people are to have an episode of depression, for example, they will get over it, particularly if we give them the correct help and understanding and do not decide, “Oh, they have had a bout of depression. They will never be able to hold a job again”. If we can get over that, we will do well. We will benefit from that as a society. In my work outside dealing with hidden disabilities, I have found that embracing small changes in attitude and approach benefits the whole of society, not just that person. That process is not easy.
I must make a small confession to the noble Baroness, Lady O’Neill. When I first heard in my work with disabilities that mental health was to be put in with disabilities, I was a little frightened. I thought, “Wait a minute. With illness, you either get better or you die. It is not something that is with you for life”. I was rapidly disabused of that, because the prejudice that goes with it will be with you for life, as with cancer, which has been mentioned. The idea that it marks you out as different and other is incredibly important. I came to the conclusion: “It ain’t a perfect fit, but it—putting them together—is definitely the best show in town”.
We must try to get this across and start to engage with the rest of society about it. On the similarity between physical conditions and mental ones, I discovered many years ago, backed up by my personal experience, that many things that we do to prevent physical ill health work for mental ill health. There is lots of evidence, as Mind has recognised, that physical exercise releases hormones that help with many conditions. If you are physically healthy, you are considerably less likely to suffer from many forms of mental ill health. Encouraging physical activity can help many mental health conditions. The interrelationship between the two types of health is so close that it is ridiculous that we have to go through this process, but we clearly do.
The Government have taken this on board and are moving forward. I hope that we are not merely travelling with the tide but trying to inject some pace ourselves—running up a sail or putting an oar in the water—to go a little faster than general public opinion. There is a time lag within government and certainly in legislation. When Parliament becomes aware of a problem and then has to do something about it, it tends to jump ahead on the problem. I hope that we are seeing the first stage of that here. I am reasonably convinced that we are, but unless the Government now act and use the tide of public opinion, we will always lag behind.
We are dealing with a normal process here, a normal part of society. Unless the Government not only take the administrative steps but add to public awareness, we will be missing an opportunity to deal with a problem that will be with us for a long time. It is not going to go away, and unless we take coherent and sensible action now, we will be dealing with it for ever, normally within our prisons and hospitals.
Baroness Meacher (CB)
I should like to begin with a very brief response to my noble friend Lady Murphy. The answer to this debate, in my view, is not a redistribution of resources from the secondary mental health services to the primary but, rather, to seek to focus resources on to or into NICE-recommended treatments in both the primary and secondary sectors. An enormous amount can be achieved if we really focus on that objective.
Despite having worked in the secondary mental health services for about a quarter of a century, on and off, I shall concentrate my brief remarks on the lack of parity of esteem in the availability of treatment for children with mental as against physical disorders. I applaud the Government for at least introducing the objective of parity of esteem. I think it is fair to say that we have never had it before.
I have the benefit of access to the draft of a new book on mental health to be published by my noble kinsman Lord Layard and David Clark. You could say that I have access to insider information without which I should not be making this particular speech but doing something completely different.
The need for psychological treatment services for children is overwhelming. Indeed, the evidence suggests that the incidence of emotional and behavioural problems in 15 and 16 year-olds approximately doubled between 1974 and 2004—a 30 year period, of course—and has remained fairly stable since. Today, about 10% of 15 and 16 year-olds suffer with emotional or behavioural problems.
We now have a situation where these problems can be resolved but, tragically, generally they are not. My noble kinsman Lord Layard has talked about the undertreatment of adults, but for children the situation is equally bad. We know that nine out of 10 children with a physical illness will be treated. As my noble kinsman mentioned in relation to adults, only a quarter of children with a psychological problem will be treated. We are talking about children who are just not treated for a problem.
In 2010, Britain’s Royal College of General Practitioners conducted a survey of its members. One question was: “When children are suffering from depression or another disorder requiring specialist psychological therapy, are you able to get them the treatment within two months?”. The results were truly appalling. Only 6% of GPs could get the service they needed for their child patients within the specified time. The timeframe is important, just as it is for physical illness. We have maximum waiting times for specialist treatment for physical conditions, but none for depression and anxiety. Can the noble Earl give the House some reassurance that the Government will extend maximum waiting times to psychological therapies for children, not only for adults?
I applaud the coalition Government’s establishment in 2010 of a new priority for early intervention for children at risk. That followed the release of figures for the number of suicides. However, within two years there were cuts in half of our mental health services, which have surely undermined the Government’s objective. Again, can the noble Earl give the House any assurance about reversing that trend?
Why is our failure to prioritise children’s mental health so important? The answer is simple. Children with mental health problems go on to become adults with mental health problems. Surely it is better to treat children when the problems arise, rather than waiting for them to waste years of their lives in misery and unable to contribute effectively to society. That is obvious from the point of view not only of the individual but of the taxpayer. Our failure in this field is extremely costly. To give just one example, a child with a conduct disorder will cost the taxpayer roughly £150,000 more than if the child did not have the behaviour disorder. We can look at it the other way. If we spend £7,500 on a child with a behaviour problem, the cost is absolutely zero if a mere one in 20 of those children is helped. Of course, the figures are much better than that.
Some might think that the reason that the Government do not invest in those treatments is that they do not work, but we now know that, for children too, there are psychological treatments that have been shown to be effective. The treatments are very similar to those recommended for adults—cognitive behavioural therapy, in particular, and interpersonal therapy—for the common mental disorders. For conduct disorder, however—the single most common mental health problem in childhood —there is now a well established treatment, which is structured parent training. One of the biggest trials in England showed that after seven years the children whose parents had this treatment were 80% less likely to be defined as having oppositional defiant disorder than those not treated. This is a huge success rate. Even for the most difficult children, multi-systemic therapy has produced good results. So there are effective treatments available, if only they are commissioned, for our children. In 2008, however, less than half of children’s services were implementing NICE guidelines—hence my point at the beginning of these short remarks. In another survey, half the therapists said they use CBT for less than one fifth of their patients.
The Minister, as always, knows all these arguments. It will be very encouraging if he can give some assurances to the House today that improvements are being made to the availability of NICE-recommended psychological therapies for children. We are, of course, aware of the IAPT programme for children. I hope the noble Earl can assure the House that this programme will reach all our communities in sufficient depth to ensure that nine out of 10 children with psychological problems can be helped, just as their friends with physical problems are helped in nine out of 10 cases.
Lord Hunt of Kings Heath (Lab)
My Lords, like other noble Lords, I very much welcome this very high quality debate. I pay tribute to my noble friend Lord Layard not just for the speech he made but for his outstanding work in this area.
Many noble Lords have articulated current inequalities in service provision and poor outcomes for so many people affected by mental illness. The statistics are striking. There is no question that people with serious mental illness have increased levels of morbidity and are at greater risk of premature death. A link between smoking and mental health is stark. For example, some 42% of all cigarettes smoked in England are smoked by people with a mental health condition, including alcohol and drug dependency, and up to 70% of people in mental health units smoke. It has been estimated that around 30% of those suffering from a long-term physical health condition simultaneously have a mental condition. This is equivalent to around 4.6 million people in England alone and about 46% of people with mental health problems. People with schizophrenia may die up to 25 years before the average. People with a mental illness are almost twice as likely to die from coronary heart disease as the general population, four times more likely to die from respiratory disease, and are at higher risk of being overweight or obese.
I agree with the noble Lord, Lord Adebowale, that these kinds of figures are shocking. In the context of parity of esteem, they suggest that we need, as the noble Lord described it, a whole-person care approach. For 65 years we have had an almost tripartite system of meeting one person’s need through not one service but three services—the mainstream NHS, mental health and social care. We have also had a different funding system between health and social care, often with perverse incentives towards getting an integrated approach. This cannot go on.
As we live longer and the demographics change, people’s needs become a complex blur of the physical, the mental and the social. Wherever people are in this disjointed system, some or all of one person’s needs are being unmet. Every noble Lord brought forward illustrations of where that need is not being met. We know, as some noble Lords have said, that in acute hospitals social and mental health needs can be neglected. It may explain why we have so many problems with older people in our hospitals, how their condition can go downhill, and how they can often get stuck in an acute hospital because discharge becomes so much more difficult. In mental health care settings, people can have their physical health overlooked, which in part explains why those with serious mental health problems die younger than the rest of the population.
I am convinced that we need to integrate services and budgets, but we also need to see immediate action on parity of esteem. I will put a number of questions to the noble Earl, Lord Howe, about how he considers the Government and the health service are going to ensure that parity of esteem is actually delivered.
First, what are the Government’s intentions about securing fast and fair access to mental health treatment? The noble Earl’s honourable friend the Care Services Minister has already acknowledged that it is unfair that waiting times for psychological therapies are not given the same importance as those for hospital treatment. The noble Lord, Lord Layard, mentioned this in his opening remarks. We know that long waits can do enormous damage, particularly for children and young people, as the noble Baroness, Lady Meacher, pointed out to us. Yet clinical commissioning groups are not required to secure treatment within a fixed timescale. There is a real question to the Government about whether NHS England will be asked to set out meaningful standards for access and waiting in order to place this on a par with other services.
The second question is about how the Government will ensure that mental health crisis care is given the same priority as other urgent care services. Recent reports have highlighted the paucity of mental health crisis care. Too many people in a mental health crisis end up in police custody. People with mental health problems also attend A&E at twice the average rate and 24/7 access to crisis resolution home treatment teams is still patchy. I understand, and the noble Earl will know, that NHS England is carrying out an urgent care review which follows on from the current problems within A&E. As part of that urgent care review, will mental health crisis care be treated on a par with other issues?
In the West Midlands, indeed in Birmingham, we have a system called RAID, which has been developed to ensure that there is consultant psychiatric presence within A&E departments. That has proven to be successful but has also highlighted that, unless there is a service or a facility to which a patient who has come into A&E and is diagnosed as having mental health problems can be referred, you are still left with the problem about what to do with this patient. If we are going to solve the urgent care crisis we have to bring in mental health services and mental health commissioning as equal partners.
I want to ask the Minister about funding. My noble friend Lord Bragg said that funding for mental health is too far down the list of priorities. The noble Earl will know that the recent national survey of investment in adult mental health care showed the first real-terms fall in a decade. This was especially pronounced in older people’s mental health care. Of course, we do not have a tariff for mental health services. What will the Government do about this? I have heard that the department has discontinued the national survey of investment in mental health services. Can the Minister confirm that? If it is true, I ask him to reconsider. Surely it is very important for us, if we are going to be able to indentify whether parity of esteem is actually implemented, that we have the facts to look at the funding relativities between different health services.
I ask the Minister for his response to my noble friend Lord Layard and the noble Lord, Lord Stone, about how we can extend parity to investment and research. In the health service the research budget is very skewed towards medical research. Clearly medical research is very important. We have had debates about the investment in nursing research but we have not focused very much on research in mental health services. The point has been put persuasively here that, given the scale of mental health illness in this country, to starve ourselves of a large mental health research capacity seems to be a real mistake. I hope that the noble Earl will be able to say something more about this.
My noble friend Lady Warwick, the noble Lord, Lord Carlile, and the noble Baroness, Lady O’Neill, talked very movingly about the issue of stigma. There are some wonderful examples of how people have sought bravely to cope with the issue of stigma and have been very successful. There is, however, an awful long way to go. I would be interested to know how the Government think they might encourage this in the future.
Clinical commissioning groups clearly have the main responsibility for commissioning mental health services in the future. Is the noble Earl satisfied that CCGs have the capacity and, if not, what are they going to do about ensuring that they are given access to people who can help them commission services effectively? The noble Lord, Lord Carlile, asked about primary care capacity in terms of both accessibility and the skills of primary care physicians and other staff. Again, perhaps the Minister could say something about that.
The question that my noble friend Lord Bragg raised about employment was very important. In the main, we have been talking about services but we know that the links between employment and good health are very strong and I wondered whether the Department of Health was working with other government departments to encourage employers to be much more progressive in the way that they treat mental illness.
Finally, I declare my interests as chair of a foundation trust, a consultant trainer with Cumberlege Connections and the president of GS1.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I join other noble Lords in thanking the noble Lord, Lord Layard, for his tireless efforts in ensuring that evidence-based psychological therapy is available for everyone who needs it, and for convening this debate and providing me with an opportunity to assert once again this Government’s commitment to parity of esteem for mental and physical health.
The Royal College of Psychiatrists, in its recent report, Whole Person Care, describes parity as,
“valuing mental health equally with physical health”.
Equality is certainly the principle which underpins parity. As the noble Baroness, Lady O’Neill, said, equality is not just how we think about mental and physical healthcare but how they are valued. Parity of esteem is not just an abstract concept. It is the subject of an active and ongoing programme between the Department of Health and its system partners, dedicated to closing the gap with physical health services and to translating rhetoric into reality. We made our commitment explicit in the Health and Social Care Act 2012, as my noble friend Lord McColl reminded us, where we enshrined in law the equal importance of mental health alongside physical health. My noble friend Lord Alderdice was right to say that this explicit statement in statute does matter.
The noble Baroness, Lady Warwick, asked how we will improve the skills of GPs and the ability of CCGs to commission mental health services. We have made putting mental health on a par with physical health one of NHS England’s key priorities, as well as ensuring that everyone who needs it has timely access to the best available treatment. The mandate to NHS England is strong on mental health. It makes it clear that everyone who needs it should have that timely access to evidence-based services, and I can tell noble Lords that we are determined that mental health should play a similarly pivotal role in the forthcoming refresh of the mandate for 2014-15. Of course this needs investment, a point which again was made by the noble Baroness, Lady Warwick. We must remember the role of government here: as she knows, the Government set the outcomes that they expect the NHS to achieve in the NHS outcomes framework. There are a number of outcomes specifically for people with mental health problems and others about the quality of services, and patients’ experience of them, which apply equally to mental health services.
One crucial measure is that of excess mortality. It is up to commissioners to prioritise their resources to meet these outcomes for the population, based on assessments of health need, while taking into account the mandates requirement to make demonstrable progress in achieving parity of esteem for mental health services. We will hold the NHS to account for the quality of services and outcomes for mental health patients through the outcomes framework but it is worth noting that in 2011-12, the total invested in mental health services for working-age adults was £6.629 billion, or £193.30 per head of weighted working-age population.
The noble Lord, Lord Layard, my noble friend Lady Tyler and the noble Lord, Lord Hunt of Kings Heath, raised waiting times for mental health and the noble Baroness, Lady Meacher, was particularly concerned about waiting times for children. We are clear that mental health treatment should be available for those who need it and we have asked NHS England, through the current mandate to the NHS, to look into waiting times for mental health treatments. We will be expecting progress on this and my honourable friend Norman Lamb will be taking a close interest in the progress that is made.
The noble Baroness, Lady Murphy, reminded us that too many people with mental health problems die prematurely. We know that people living with significant or persistent mental illness have significantly reduced health and quality of life. They live on average 16 to 25 years less than the general population. That is why reducing premature death in people with serious mental illness is defined as an improvement area in the NHS outcomes framework and why the NHS operating framework specifically focuses on the physical healthcare of people affected by mental illness for the coming year.
The noble Lord, Lord Adebowale, reminded us of the disproportionate burden of mental illness experienced by people from BME communities. We know that black and African-Caribbean men are more likely to be detained under the Mental Health Act. The reasons for this are complex. I can present him with no simple answers; we recognise that more work needs to be done to establish the causes of higher rates of mental illness in some communities and how communities access early intervention services. We are in discussion with a number of BME leaders and influencers on this. I recognise the concerns about incidents in recent years where someone with a mental health condition has either died or been seriously injured after police contact. I welcome the report of the independent review led by the noble Lord, Lord Adebowale, and I echo his view that it is important to get to the truth of matters with clarity of focus and to remove any excuses for not taking the chance to improve practice.
I listened with care to the noble Baroness, Lady Murphy, who called for more psychiatrists. We are supporting local organisations in taking effective action to improve mental health. Our mental health strategy and implementation framework and our suicide prevention strategy focus on specific actions which specific local organisations can take to improve mental health across the life course in their areas. We are investing more than £400 million to give thousands of people, in all areas of the country, access to NICE-approved psychological therapies. The mandate to NHS England makes it clear, as I have said, that everyone who needs it should have timely access to evidence-based services. This will involve extending and ensuring more open access to the Improving Access to Psychological Therapies programmes, in particular for children and young people and for those out of work. My honourable friend the Minister of State for Care Services will be meeting system partners monthly to ensure that IAPT is being delivered.
My noble friends Lady Tyler and Lord Carlile and the noble Baroness, Lady Meacher, spoke about the importance of parity for children and adolescents. Children’s mental health is a priority for the Government. We are investing £54 million over four years in the Children and Young People’s Improving Access to Psychological Therapies programme, giving children and young people improved and timely access to the best mental health care. It will of course be up to NHS England, working with local commissioners, to decide how to spend this money in the most effective way.
Parity is also core business for the reformed health and care system. Key bodies within the system are addressing this. NHS England is working with national clinical directors and others to develop a programme of work with the dual objectives of delivering parity of esteem across the health and care system and supporting NHS England, as an employer, to promote parity of esteem. The priorities here include: support for people with mental health problems following early diagnosis, particularly through appropriate use of primary care and supporting the roll-out of health checks; ensuring people have access to the right treatment at the right time; and measuring and publicising outcome data for all major services by 2015. In other words, they are making every contact with patients count. There will be a statement very soon from NHS England on this. I obviously cannot pre-empt that here but it will set out the detail of this programme of work.
In that context, I pick up a point made by the noble Lord, Lord Stone, about NICE. NICE clinical guidelines are, I put it to him, in no way inferior products to technology appraisals; they often perform a valuable role in putting NICE’s technology appraisal recommendations into the context of the overall care pathway for patients.
My noble friend Lord Carlile rightly emphasised the importance of attending to the mental health of the elderly, but here again it is right for me to point out that the mental health strategy No Health Without Mental Health is an all-age strategy: that is the approach that it adopts and it means that its focus is equally on all members of the population from the young to the old—all are equally important.
My noble friend Lady Tyler spoke about those with complex needs, particularly those who indulge in alcohol and drug misuse. Improving co-ordination between mental health, drugs and alcohol services is vital for improving outcomes for the most vulnerable and excluded. Practitioners may also be involved in the design, planning and delivery of high quality services and are well placed to help GPs and local partners in commissioning high quality services.
My noble friend Lord Carlile spoke of the need for therapists in the community and I listened with care to what he said. Secondary mental health services have been reorganised to improve care in the community and in hospital and timely care and treatment is increasingly offered in the most suitable and least restrictive environment. Even though there are more people being treated in secondary mental health services, the proportion who needed to be admitted to in-patient psychiatric care fell by 2.9% in 2010-11. Acute beds have got to be there for those who need them, but providers have a responsibility to listen to patients and offer care in the community as well as in hospital.
Public Health England is embedding mental health across its work, including developing a national programme for public health mental health. This will support No Health Without Mental Health, prioritising the promotion of mental well-being, the prevention of mental health problems, the prevention of suicide and the promotion of well-being for people living with and recovering from mental illness. I refer to an issue raised by the noble Lord, Lord Hunt, about a focus on reducing smoking. Public Health England’s work plan in relation to mental health and well-being will include a specific part on smoking cessation.
The noble Baroness, Lady Murphy, and my noble friend Lord Alderdice spoke about suicides. Suicide rates in England are low compared to those in other European countries but we are not complacent about these figures, which is why we launched the new suicide prevention strategy in September of last year. The strategy can help sustain and reduce further the relatively low rates. As well as targeting high-risk groups, improving the mental health of the whole population can, of course, prevent suicide and the mental health strategy has that all-population approach, as I mentioned earlier.
Supporting parity is also a key objective of Health Education England. The Government’s mandate to Health Education England recognises the importance of professional culture to achieving parity. It tasks them with ensuring that the mental health workforce has the skills and values to improve services and to promote a culture of recovery and aspiration for their patients. It also notes the importance of mental health awareness in the wider health workforce. My noble friend Lady Tyler argued that maternity services need to look for early signs of mental ill health; I do, of course, agree with that. Mental health is a matter for all health professionals including midwives and health visitors. The Government’s mandate to Health Education England includes the commitment to ensure that all healthcare staff are equipped to treat mental and physical conditions with equal priority.
The noble Lord, Lord Layard, referred to the need for research. As a prerequisite for parity of esteem, ensuring that we have the right data, the right measures, is absolutely essential. One of the most important roles the centre can play is gathering and distributing information about mental health in order to inform evidence-based commissioning and service delivery and that is why NHS England and Public Health England are jointly working to establish a national mental health intelligence network which will be a key driver of continuous improvement in mental health intelligence and information. The noble Lord, Lord Hunt, asked whether the Government are discontinuing the adult psychiatric morbidity survey. The department and the Health & Social Care Information Centre are currently discussing plans for the next survey which should take place in 2014.
My noble friend Lord Carlile spoke about stigma. True parity also requires a shift in attitudes, not just in service providers but across society as a whole. That is why we are investing up to £16 million in the Time to Change programme, supplemented by a further £4 million from Comic Relief. This ground-breaking programme works to empower people to talk about mental health problems and to tackle the discrimination that they face. We aim to make Time to Change reach 29 million people and increase the confidence of 100,000 people with mental health problems to challenge stigma and discrimination.
I say to the noble Lord, Lord Bragg, that the mental health needs of people in the workplace have not been overlooked. Helping people with mental illness find and sustain work is a priority across the health and care system. A measure of employment for people with mental health problems features in all three outcomes frameworks. We are also challenging the stigma and discrimination experienced by people with mental health problems, as I mentioned, in the Time to Change programme and I regard that programme as very much aimed at employers and those whom they employ.
The noble Lord, Lord Layard, suggested that there should be a Cabinet Minister for mental health. While there is not a Cabinet Minister whose sole responsibility is mental health, this does form an important part of the portfolio of the Minister for Care and Support, my colleague Norman Lamb, and I know that this is also one of his personal priorities. We are actively encouraging every government department to pledge its support for the Time to Change campaign and ensure that mental health issues are taken into consideration in policy-making and planning across government.
I hope that the noble Lord, Lord Layard, will think I am right to celebrate some of the achievements to date, but the scale of the challenge ahead should not be underestimated. It will require significant changes to the way mental health services are delivered locally, based on a clear understanding of local needs and with the accent firmly on delivering better outcomes for users. There are exceptional services that others can learn from, but as we move forward a focal point must be more effective collaboration between public services, to enable early identification of mental health problems and to provide more co-ordinated care.
In that context, I pick up a point raised by the noble Lord, Lord Stone, about the police and their interactions with those with mental health issues. I referred to this briefly earlier. We know that we have to have an effective emergency mental health response system in place and we have asked all the relevant organisations, including the Home Office and the Association of Chief Police Officers, to draw up an agreed plan to tackle this problem. Street triage teams, currently being piloted around the country, partner mental health clinicians with police officers to attend emergency responses involving those with suspected mental health problems.
Of course, more needs to be done for acute and crisis care, a point made by the noble Lord, Lord Adebowale. Improving acute mental health services is a key priority for the Government, as identified in the first mandate to NHS England and underpinned by the outcomes framework. As I have said, we are clear that where someone needs an acute bed, it has to be there for them and there has been significant capital investment in the mental health in-patient environment in the past decade.
All of this matters, because achieving parity is a challenge which extends far beyond health and social care. It requires a genuinely cross-government approach, involving all aspects of public service delivery as well as many partners across the voluntary sector. Momentum is gathering and over the months to come I am confident that we will progress further and faster towards our end goal.
Lord Layard
My Lords, I thank everyone who has spoken in this substantial debate. We have had 15 excellent contributions and somehow, miraculously, they have been almost entirely complementary to each other, so in some way we have written a pretty good textbook on the subject in these three hours. As everyone has said, this issue is a massive problem, which is why we are all extremely grateful to the Minister for taking this problem seriously today, and indeed I know that he takes it seriously on all occasions.
I am grateful for what people have said and I agreed with almost everything, including most of what the noble Baroness, Lady Murphy, said, on which I, too, would like to comment. It is quite misleading to suppose that there is something called the mental health budget, which is then allocated between psychotic illness and common mental health problems. We have never argued for more expenditure on anxiety and depression at the expense of severe mental illness. What we have pointed out is the remarkable fact that a mentally ill person with a physical illness of given severity costs the NHS 50% more in physical healthcare than someone without mental illness in the same physical condition. If we can cure the mental illness or alleviate it, there is an awful lot to be saved on unnecessary physical healthcare.
Most commissioners should be able to fund the extra psychological therapy out of the savings that they can expect from their physical healthcare bills, particularly their references to the secondary sector. One could document how those are affected immediately when someone’s mental health improves. There is a huge amount of evidence on all that. On top of that, of course, taking the Government as a whole, there are the savings on benefits and lost taxes. When we can say that it certainly costs the Government—and probably costs local commissioners—nothing to expand treatment for people with depression and anxiety disorders, which are extremely serious problems, it makes no sense to say that we should be concentrating only on people with even more serious problems. Both groups must be helped.
As I said, there have been many wonderful speeches. I thought that the letter read out by the noble Baroness, Lady O’Neill, really says it all; it caught the basic point that everyone is making. I was also delighted when the noble Lord, Lord Alderdice, raised the issue of the comparative suffering from mental and physical pain. I have been trying to look into that topic and have found quite a lot of research on it. Many studies show that when people are asked how happy they are with their lives and then record the different dimensions of their health situation, it is found that mental pain reduces happiness more on average than physical illness. In a way, we have to justify our argument for parity of esteem, and I think that that is the justification: these are extremely serious conditions affecting the well-being of the people affected. Many people have made that point, and it is a central argument for parity.
I think that if in decades hence we look back on where we are today, we shall be able to see a lot of progress. I think that people will be amazed when they look at how mentally ill people were treated, even now, and they will find it quite difficult, just like we find it difficult to believe how slaves and so on were treated, to believe that we treated mentally ill people with as much blindness and cruelty as we have been up till recently.