Mental Health: Ensuring Equal Access to Mental and Physical Healthcare

Baroness Tyler of Enfield Excerpts

Thursday 26th May 2016 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, in my contribution to the debate on the gracious Speech last week, I said that mental health had become one of the defining challenges of our age. I am delighted that today’s debate, secured by my noble friend Lady Brinton, provides an opportunity to expand on this. We have already heard today that one in four people experiences a mental health problem in any one year, so it really is an issue that touches each and every one of us at some point in our lives. The moral arguments are overwhelming, too. As Michael Marmot so powerfully reminded us in his recent book, The Health Gap: The Challenge of an Unequal World, people with mental ill health have a life expectancy between 10 and 20 years shorter than people with no mental illness. Doing something about this is a first-order issue for social justice.

Let us look at the big picture. Demand for mental health services is rising relentlessly and will continue to do so. It has been estimated that by 2030 there will be approximately 2 million more adults in the UK with mental health problems than there are today. Mental health services must be equipped to respond to increasing and changing demand and be able to tackle unmet need—that is a huge challenge. It is undeniable that mental health is getting much more attention from politicians and policymakers, and that is a good thing. But what actual difference is that making to those one in four people? That is what I want to focus my remarks on today, as well as offering a few concrete suggestions on how we start turning all these fine words into reality.

So, what is the overall strategy for addressing this issue? In a recent exchange in your Lordships’ House at Question Time, the noble Lord, Lord Prior, was asked when the Government would be producing their strategy on mental health. The Minister replied by saying that the Mental Health Taskforce report, along with the Future in Mind report and the report from the noble Lord, Lord Crisp, on acute psychiatric care, were the strategy. Although I am quite a fan of strategy documents myself, I thought that that was quite a good answer, and so reviewed them to see if they did add up to a comprehensive strategy.

First, Future in Mind, published just before the election, was a much-needed blueprint for modernising and improving children and young people’s mental health and well-being, backed up by £1.25 billion in funding. It highlighted the fact that 75% of mental health problems start before the age of 18 but that less than 25% of young people with a diagnosable condition were accessing support and treatment. Its almost 50 recommendations for transforming services for children and young people looked right across—from preventive work and early intervention through to crisis care. It was, in my view, a very good report.

Secondly, the excellent report by the noble Lord, Lord Crisp, Old Problems, New Solutions, on improving acute psychiatric care for adults, makes a compelling case for patients with mental health problems having the same rapid access to high-quality care as patients with physical health problems. As we have heard, the report recommended a new waiting time pledge for admissions to acute psychiatric wards and the phasing out by 2017 of the practice of sending acutely ill patients far from home for non-specialist treatment. I would like to add my voice to the other voices this afternoon saying that we should not have to wait until 2020 for that to happen, not least given the expert opinion that this practice is associated with an increased risk of suicide—as we have heard so powerfully and personally this afternoon from my noble friend Lord Oates.

Finally the Mental Health Taskforce report provided a comprehensive insight into the current state of mental health care. Its verdict was striking. It says that,

“too many people have received no help at all, leading to hundreds of thousands of lives put on hold or ruined, and thousands of tragic and unnecessary deaths”.

Those are strong words indeed. With 75% of people affected by mental health issues receiving no support at all, the report makes it clear that the current mental health care system is simply not coping as a result of years of chronic neglect and underfunding. The report also made more than 50 recommendations. Priority actions were: access to mental health care 24/7 as part of a seven-day NHS, new waiting time and access standards, and expanding access to psychological therapies to help more than 600,000 people. The report also had a lot to say on a more integrated approach to mental and physical health, recognising how interconnected the two are for many people.

In my assessment, these reports taken together do give us the overarching framework needed for transforming mental health care, so I am with the Minister on that point. So, “Job done?”, noble Lords may ask. Clearly not, because after all of this very good work and three excellent reports, we are simply at the starting line. The task of turning the rhetoric and good words into reality is Herculean, and all our attention should be focused on it. Central to this will be political will and sustained financial investment, along with far better data and much sharper accountability mechanisms.

I previously welcomed the government commitment to spend an extra £1 billion on mental health in 2020-21. I noted, however, that that extra money will come through only in 2020-21 and that in the years preceding, significantly less money will be available. Indeed, mental health services will be expected to make significant savings alongside the rest of the NHS. So when summing up, will the Minister spell out precisely how much money will be available in each of the financial years between now and then? We have already heard about the recent survey showing that most providers and commissioners do not feel confident that £1 billion will be sufficient to meet the challenges already outlined, given the historic underfunding of mental health services and the deficits that so many NHS trusts face. Of particular concern is whether this funding will be adequate to roll out the services needed to meet the first ever waiting standards for depression and anxiety and for early intervention in psychosis, introduced by the coalition Government, as my noble friend Lady Brinton told us. What reassurances can the Minister give me on that point?

The task force’s very welcome commitment to introduce comprehensive waiting time standards is critical to bringing mental health in line with physical health and to fundamentally changing the culture. To turn the tanker around, these standards need to be accorded the same status as four-hour A&E targets, cancer waiting times and the 18-hour referral-to-treatment targets. However, the chief executive of NHS England, Simon Stevens, recently confirmed that the £1 billion by 2020 will not be sufficient to deliver comprehensive waiting time standards. Indeed, that assessment was backed up by a recent NAO report which found that achieving the standards would be “a very significant challenge”. In summing up, will the Minister please confirm whether the Government are still committed to fully funding these standards, which are at the very heart of parity of esteem?

Turning to funding for children and young people’s mental health, the additional and very welcome £1.25 billion secured in the April 2015 Budget to back up the Future in Mind report should amount to £250 million in each year of this Parliament. But as we have already heard, in reality, only £143 million was spent in the last financial year, with only £75 million of that going directly to CCGs to improve local services. That raises the question of why there was a delay in getting resources through to the front line of children’s mental health services. I know that capacity issues have been cited by the Government, so will the Minister please say what progress has been made on the workforce recommendations contained in Future in Mind, and when the roughly £100 million funding shortfall in 2015-16 will be forthcoming?

Along with adequate funding, we need far greater transparency about how money allocated at national level reaches the front line of mental health services and which mental health services are being prioritised. Frankly, it is worrying that it took a freedom of information request last year to find out that some 50 out of 130 CCGs were planning to reduce spending on mental health. The recent updated planning guidance from NHS England tells CCGs to increase in real terms their spending on mental health by at least as much as their overall allocation increases, and that is of course welcome. However, it is vital that proper tracking mechanisms are in place to ensure that CCGs are held to account on how much they spend and the impact that is having on their communities. In turn, that calls for far better data collection at local level on spending, including how much is being spent on different types of services and treatments. At present, we have what the Minister himself in this House has called a data black box. That is really holding back progress on the much-needed transparency and accountability.

One of the main ways of holding CCGs to account is the improvement assessment framework, which measures CCGs against specific targets. It was therefore very disappointing that the newly published framework does not include a specific assessment of how much CCGs spend on mental health provision in their areas. That was a real missed opportunity. I fully understand the severity of the overall pressures on CCGs, but they were exemplified most starkly in a rare move recently when the Mental Health Commissioners Network wrote to the Department of Health asking that money for young people’s mental health care be ring-fenced so that it is not siphoned off to pay for other services. I have to say that that is something I personally would support. I understand that the department has replied, saying that it does not have the legal powers to do that, so I turn to the legal position for a moment.

In the debate on the Speech I said that equal access to mental health care should be enshrined in legislation. At present, apart from a general reference to parity of esteem between mental and physical health in the Health and Social Care Act 2012, the only specific pieces of mental health legislation of which I am aware are the Mental Health Acts 1983 and 2007 and the Mental Capacity Act 2005, and they deal with completely different issues. So while I do not generally support the use of legislation to send policy signals, my sense, backed up by everything I have heard in the debate today, is that legislation in some form or legislative underpinning is needed to achieve the fundamental culture change we need.

One way of achieving this, in my view, would be for waiting times and access standards to be included in the NHS constitution and the handbook to it which the Secretary of State and all NHS bodies are required to take account of. Then people would know that it is an entitlement, not an aspiration or a discretionary matter subject to funding and other priorities. At present, waiting times and access standards are contained only in the NHS mandate, which does not have the same status.

I want to end on a slightly more upbeat note and acknowledge that critically important as money, data and accountability are, they are not the whole answer. There is a mindset issue and an issue about working collaboratively. I have the privilege of chairing the Values Based Children and Adolescent Mental Health System Commission, as declared in the register. The commission started its work earlier in the year and will report in September. In short, it is looking at how we can improve the commissioning and delivery of the children and young people’s mental health system to take better account of what really matters to all involved, most particularly the children and young people themselves. What sort of services, delivered in which way and where, would they like to see? We have received wide-ranging evidence from witnesses across the UK and I am particularly encouraged by some of the examples we have heard in different localities where services have been transformed by CAMHS, schools, local authorities and the voluntary sector coming together, collaborating and pooling budgets. The result is that some places have been completely redesigned around the needs of children and young people and their families. This redesign is generally based on a system-wide approach comprising early intervention and preventative services, often based in schools, with schools acting as hubs, working in tandem with target specialist and crisis services, the latter available on a 24/7 basis. Interesting features include a single point of access, no wrong door, open access and far fewer thresholds. Far more young people in these areas are getting the help they need and the money is being spent far more effectively. I look forward to bringing the findings of the commission to your Lordships’ House.

I am conscious that I have asked rather a lot of questions and I am quite happy for the Minister to reply to me in writing on some of them.