Carers: Health and Well-being

Baroness Tyler of Enfield Excerpts

Tuesday 12th June 2018 Lords Chamber

[Lord O’Shaughnessy]

The importance of respite care is agreed by everybody. I point my noble friend to the better care fund, which provides around £130 million a year to support respite care and carers’ breaks, building on the commitment made in the Care Act 2014.

[Baroness Tyler of Enfield (LD)]

My Lords, the action plan contains a number of generalised statements about the need for health and social care professionals to have improved understanding and awareness of the needs of carers. What specific plans do the Government have to ensure that social worker training—both initial training and later professional development—contains practical guidance on how to identify carer fatigue and distress and ensure that carers receive the support to which they are entitled?

[Lord O’Shaughnessy]

The noble Baroness makes a very important point. Indeed, in the carers action plan there is a specific commitment from the department to work with local authorities to improve social work guidance in terms of spotting carers, many of whom are not even aware that they are formally designated as carers, and signposting them to the right support. There will also be an awareness-raising campaign among social workers so that they understand their duties.

The Long-term Sustainability of the NHS and Adult Social Care

Baroness Tyler of Enfield Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, in its excellent report, the Select Committee chaired by the noble Lord, Lord Patel, makes it plain that very significant investment in the NHS and social care is needed to ensure its long-term sustainability and avoid further damage both to the quality of and the access to care. Indeed, it is no exaggeration to say that the current system is near breaking point. We cannot carry on patching a gaping wound with a sticking plaster.

The recent Nuffield Trust report said that public satisfaction with the NHS is falling. The main reasons cited included staff shortages, long waiting times, lack of funding and government reforms. Primary care is particularly underfunded and overstretched, placing far more pressures further downstream on hospitals. A recent Daily Mail survey found that one in seven patients had to wait longer than a fortnight for an appointment with their GP. In a report earlier this year, the King’s Fund describes public health as dying from a thousand cuts. All the evidence shows that, to mitigate further costs, we must greatly ramp up our public health efforts to prevent disease. That was well addressed in the Select Committee report—but where is the response?

As the Select Committee report plainly stated, the issue of the workforce,

“represents the biggest internal threat to the sustainability of the NHS”,

and I want to focus most of my remarks there. As we heard in our recent debate in this Chamber on Brexit and the NHS, there are roughly 40,000 vacancies in nursing. Yesterday, the Guardian reported three times more departures from nursing than before Brexit. I was struck by a piece on Monday’s “Today” programme about GPs leaving because of the immense stress and pressure that they were under, which left patients in Plymouth regularly waiting two to three weeks for an appointment and one patient calling 93 times to be connected with her doctor. Britain has fewer GPs per person than other wealthy countries and, like nurses, they are leaving faster than they are coming. Those shortages increase the strains further down the system in the more expensive bits of the health service. A trip to the GP costs less than one-third of a visit to A&E. But nowhere is the situation more acute than in the mental health sector. Psychiatry is experiencing some of the highest vacancy rates—between 15% and 20%, with mental health nursing at 15%. In the current climate, it is salutary to note that some 40% of mental health staff come from overseas.

So what is being done about this? Health Education England’s recent draft workforce strategy provided, frankly, precious few solutions. There is a distinct lack of detail, with no modelling for the future NHS workforce beyond 2020-21. A better plan must surely look beyond the culture of short-termism to staffing solutions that can meet long-term demand, address supply issues, promote innovative and technological change and consider—this is really critical—new roles for health professionals and new ways of working for doctors and nurses. This should include applying best practice from overseas and looking at radical reconfiguration of services.

In addition, we must ensure that the workforce operates within far more efficient systems that allow people to get on with their jobs and to spend the time they need with patients rather than dealing with regulation and bureaucracy. Some of our current systems are very unproductive compared with other countries, which other speakers in this debate have touched on. It is clear that the NHS has yet to get to grips with these critical and worsening workforce issues and the current—opaque, I feel—division of responsibility between NHS England and Health Education England is not helping. Can the Minister, when he concludes, say who is ultimately responsible for the long-term planning on these key issues, such as workforce planning and productivity?

Turning specifically to mental health, what should be read into the fact that the key recommendation relating to mental health regarding parity of esteem was totally ignored in the Government’s response? To say it is not encouraging is something of an understatement. What does it say about the Government’s commitment to integrated care? The mental health investment standard is the statutory requirement to increase mental health investment in line with other services. However, recent data from the Royal College of Psychiatrists shows that more than one in 10 CCGs are failing to meet this standard. Can the Minister also say what action the Government intend to take in this area?

It sometimes feels as if we are engulfed in a veritable blizzard of new initiatives of the alphabet soup variety—we have STPs, ACOs and vanguards; I looked on the NHS website and there are a raft of others. I did not really understand what they even stood for and, frankly, it was impossible to understand how one related to another. We know the sustainability and transformation partnerships were set up to integrate health and social care across wide geographical areas, which is absolutely key to sustainability. But STPs have been told in no uncertain terms that they must prioritise cutting debt over everything else.

Achieving long-term sustainability will also need a far greater emphasis on integrated care. If I had more time—which I do not—I would give an excellent example in my own area, at the Whittington Hospital and the Highgate Hospital, of mental health and physical health having a really excellent physical health liaison service and working well together. From these small seeds longer-term change can grow, but it needs real political will and leadership.

On the big picture for future funding, I have been very interested to hear politicians of all stripes and other expert commentators talking about various ideas, including the Liberal Democrats’ long-term funding solution for the NHS and social care, which is a progressive hypothecated tax. Cross-party consensus is important and I hope that a cross-party commission will be set up. I am very rarely disappointed in the noble Lord, Lord Hunt, but I was disappointed at the beginning of this debate when he said that he did not think that was a good way forward. I think it is. We await further details from the Prime Minister on the long-term funding settlement but, frankly, we cannot wait much longer. Unlike previous cash injections that have gone into the black holes of hospital trust debt, any new funding must go to radical reform and, particularly, more resources for primary, community and mental health care.

To conclude, the time is right for a national conversation on all this; it is long overdue, which is something that I think the noble Lord, Lord Turnberg, said. The time is right for it now. The general public have responded quite positively to ideas such as an earmarked tax, as long as it is tied to deliverable promises of real improvements in the health and social care that they receive and they know what they will be getting for their money. This is where we really need to focus moving forward.

Brexit: Health and Welfare

Baroness Tyler of Enfield Excerpts

Thursday 29th March 2018 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I, too, congratulate my noble friend Lady Brinton on securing this vital debate and introducing it so powerfully. I was also very moved by the compelling personal testimony that we heard from a number of contributors to this debate.

As we have discussed in this Chamber on many occasions, the NHS and social care sector—and we simply must see it as one integrated picture, not two separate sectors—has been struggling to cope under tremendous pressures for too long now. We have already been hearing—and we heard it powerfully in today’s debate—how Brexit and the ongoing negotiations are compounding existing serious problems. At last week’s debate in another place on this very subject, it was frankly alarming to hear details of the flight of EU staff from across the NHS. My right honourable friend Tom Brake explained that this flight was because EU staff had been hit by what he called “a triple whammy”. He explained that not nearly enough had been done since the referendum to make NHS staff feel valued and appreciated in the UK. With the falling pound, their salaries are now worth less back home and, as the UK economy slows behind the G7, they are increasingly likely to miss out on more lucrative jobs there too. These reasons to leave, he said, are sadly also reasons why critical talent with skills that we are crying out for in the UK are now thinking of not coming.

In that same debate, Dr Lisa Cameron MP reported that nearly half of EEA doctors have said,

“that they were considering leaving the UK following the referendum vote”.—[Official Report, Commons, 22/3/18; col. 228WH.]

As a Londoner myself, I was alarmed to read of a recent poll of doctors, in which 86% of London doctors who responded believed that leaving the EU will have a negative impact on recruitment to the NHS in London. These perceptions really matter.

In 2017, for the first time in a decade more nurses left the profession than joined. Indeed, the Commons Health Select Committee reported that the proportion of EU nurses choosing to leave the NHS has risen by a third in just one year. Critically, Nursing and Midwifery Council data shows that in the year following the referendum there was a fall of 89% in new EU registrations. Meanwhile, the social care sector is being drastically hit too, with the Nuffield Trust predicting a possible shortfall of 70,000 carers by 2025. We all know how shortages in social care exacerbate problems in the NHS and vice versa. I am sorry to quote so many statistics, and I know that other noble Lords have quoted many figures too, but it is really important that we understand the big picture. To say that it is not encouraging would frankly be a bit of an understatement.

I am particularly concerned about staffing in mental health services, and that is going to be the main focus of my remarks today. Though the staffing data for NHS mental health services is not as good as it could be, the available information is also not encouraging. According to the King’s Fund, there has already been a 13% reduction in mental health nurses since 2009, with in-patient care nurses being reduced by nearly a quarter. According to the Royal College of Psychiatrists, child and adolescent psychiatrists have fallen by 6.3% since 2013, something that we debated yesterday at Question Time. Currently, almost a 10th of all posts in specialist mental health services in England are vacant, and the mental health network of the NHS Confederation warns that it simply will not be feasible to meet health and social care staffing needs through domestic recruitment, training or non-EEA recruitment.

The conclusion that I draw from this is that psychiatry, as a shortage specialty, is under stress. We are undeniably struggling to fill roles, and we are highly reliant on international trainees, with more than two out of five coming from abroad. That is the highest of any medical specialty. Any exodus of EU-trained psychiatrists would throw an already overstretched system into crisis. The Government’s plans to recruit an additional 570 consultant psychiatrists by 2021 might be welcome, as are their plans to recruit child and adolescent psychiatrists and other mental health staff set out in the recent Green Paper. But as the Royal College of Psychiatrists reminds us, it takes 13 years to become a fully qualified psychiatrist, and the scale and ambition of these plans will work only if medics choose to become psychiatrists.

What is the effect of all this happening? As staff and budgets are strained across the NHS, morale is taking a hit, and consequently, outcomes for patients can suffer too. A recent Guardian survey of NHS staff showed that only 2% of participating staff felt that there were always—it is important to stress that word—enough people to provide safe care. As someone who has had occasion to use the NHS quite a bit recently, I find these figures truly shocking and frightening.

What are the Government doing about these alarming trends? In response to the debate in the other place I already mentioned, the Minister of Health, Stephen Barclay, seemed intent on ignoring the mounting evidence of EU staff’s flight from the UK and instead repeated a single figure that seems to justify the Government’s position, saying repeatedly that 3,200 new EU staff were working for the NHS. However, as the helpful briefing pack for this debate produced by the Library pointed out, this number is almost certainly inaccurate. The increase reflects an improvement in the way we record this information; in the same timeframe, more than 10,000 staff are no longer counted as “unknown nationalities”.

Pay is clearly an important factor in recruiting and retaining staff in the NHS. Although of course I welcomed the news of an end to the NHS pay cap, it seems that a pay rise of 6.5%—which sounds good, and I am sure it is welcome—may not amount to that much in real terms. If the OBR’s inflation forecasts are accurate, a 6.5% pay rise will increase pay by just a third of 1% in three years, still leaving wages significantly below what they were in 2010.

Similarly, the recent announcement to increase the number of midwifery training places offered, while again welcome, may not be enough to make our system sustainable. As with psychiatrists, the increase in these fee-paying places may increase the number of newly trained midwives in the UK from 2022, but there is little guarantee that these extra places will be taken up by students or that those who study will necessarily be employed by the NHS once they graduate. The only way to ensure that we have a real shot at making the UK a safer place to give birth will be through further incentivising training, recruitment and development of midwives at home and abroad, not simply offering more places.

I do not wish to sound simply like a counsel of despair—although there is a lot to be gloomy about—but I will suggest some positive steps that the Government should be taking. As the noble Baroness, Lady McIntosh of Pickering, so forcefully said, we need to see a much greater sense of urgency from the Government. First and foremost, we must move beyond mere lip service and demonstrate how much we value the contribution of our health and social care staff. Parliament has an important role to play here in the way we talk about these issues and in the language we use. There are other concrete steps that we can take to make the UK a more attractive place for people to work.

The UK must continue to welcome new doctors and provide urgent guarantees to those working here as to their rights under future residence. We should also give clarity to those who might come during the 21-month transition period as to their rights. We must better recognise EU and overseas professional qualifications to reassure doctors that their skills are respected, and broaden the national shortage occupation list to include staff with much-needed skills from the EU—a point I made yesterday with regard to psychiatrists. The visa application process for international staff should be simplified, streamlined and improved, and the Medical Training Initiative—a government-approved exchange programme—should be extended and enlarged to send a message to the world that the UK is not closed to foreign doctors. I hope the Minister will respond to those points. I have one specific question for him. Would the Government consider extending the cap on the length of the Medical Training Initiative to give more international psychiatrists and other medical professionals a chance to work for a period in the NHS while alleviating our workforce challenges?

I am pleased that the Prime Minister, albeit very late in the day, has come to recognise that the NHS needs significantly more funding and has started to talk about a long-term funding settlement. This revelation was no doubt helped by the broad coalition of MPs pushing for the adoption of the Liberal Democrats’ proposals to sustainably fund our NHS and social care through an earmarked tax. There is growing public support for such a tax because the public recognise the pressure that the NHS is under and it is so important to them in their lives. I strongly encourage the Government to include the cash-starved social care sector in the funding plan and to implement these proposals soon, in order to signal to the British people and the international community that we are serious about maintaining the best health system in the world.

Children and Young People: Mental Health

Baroness Tyler of Enfield Excerpts

Wednesday 28th March 2018 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, given that the number of child and adolescent psychiatrists has declined by over 6% since 2013, and the number of mental health nurses by more than that, will the Government agree to consider the recommendation from the Royal College of Psychiatrists to add child and adolescent psychiatrists to the national shortage occupation list?

[Lord O'Shaughnessy]

There has undoubtedly been an impact on mental health nursing. In fact, the widest definition of the mental health and learning disability workforce according to the latest workforce stats is up by around 3,000 full-time equivalent posts. But we agree that more needs to be done. That is why there is an ambition to bring in 4,400 more mental health staff to support children and young people over the next few years. It is also reassuring to know that there are 8,000 mental health nurses in training at the moment.

Mental Health: Young People

Baroness Tyler of Enfield Excerpts

Thursday 9th February 2017 Grand Committee

[Baroness Tyler of Enfield (LD)]

My Lords, I congratulate the noble Baroness, Lady Massey, on securing this vital debate. Parental and family relationships have a huge impact on children’s mental health. This debate is all the more timely, taking place during Children’s Mental Health Week. Recent research revealed that up to two-thirds of children aged 10 and 11 worry all the time, with concerns about family and friends topping the list of causes of anxiety. Figures released last week show that more than 50,000 young people turned to ChildLine last year because of a serious mental health problem. In the light of these very worrying figures, it is hard to overstate the importance of the role of parents in supporting children with mental health problems.

In the time available, I can make only two key points. First, parents are a vital support and often a lifeline to children with mental ill-health. Given that parents spend more time with their child than anyone else involved, they have a crucial role in advocating on behalf of and supporting their child through difficult times. However, as the results from the “There for you” survey show, too often parents feel unprepared and ill-equipped to support their child and consequently struggle to play the vital role that they would like to. Indeed, the YoungMinds parents’ helpline found that 41% of parents said that they felt excluded from their child’s treatment, with other parents saying that they felt confused and isolated. We have to acknowledge that for a variety of reasons, some already mentioned, some parents are simply unable to provide the support that their children need. Obviously, there is a particular issue for children in care. Another specific concern that I want to highlight is perinatal mental health. More than one in five mothers develop a mental health illness during pregnancy or in the first year after birth. The knock-on effect of a mother’s perinatal depression on the mental health of her child can be severe.

My second point is that, as the noble Lord, Lord Farmer, reminded us, the quality of parental relationships has a significant impact on children’s well-being. Children growing up with parents who have low parental conflict, whether together or separated, enjoy better physical and mental health, better emotional well-being and higher educational attainment. Conversely, research indicates that parents who engage in frequent, intense and poorly-resolved conflict put their children’s mental health and long-term life chances at risk. In a recent survey of more than 4,000 children, family relationship problems were reported by CAMHS clinicians as being the biggest presenting issue.

We must promote greater involvement of children and parents in children’s treatment and do all that we can to ensure that effective resources are available to parents. I pay tribute to the free confidential parent helpline run by YoungMinds and its Parents Say network, bringing together parents to form a vital support network. Policy solutions and interventions need to take account of the wider family relationship in which children live and are supported. I urge the Government to prioritise support for parental-couple relationships in wider government policy, to reduce one of the often unspoken root causes of children’s mental health problems.

Mental Health: Children’s Services

Baroness Tyler of Enfield Excerpts

Thursday 19th January 2017 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, given the frankly shocking revelation that more than half of clinical commissioning groups are diverting the new money they receive to improve children’s mental health services to other priorities, will the Government commit not to sign off any sustainability and transformation plans that do not contain a clear commitment to spend every penny assigned to mental health for those purposes?

[Lord O’Shaughnessy]

The noble Baroness is a great campaigner on these issues, and I have huge respect for the work that she has done. The sustainability and transformation plans will obviously include these local transformation plans for mental health, and it is up to NHS England to ensure that it delivers on the many commitments we now have. Those commitments include the first ever access and waiting times for mental health, which is both access to talking therapies and access to help after psychotic incidents. We have new targets coming up for children and young people who seek help when eating disorders or other generic mental health problems are identified. There are robust targets and there is now a mental health improvement team in NHS England to make sure that those CCGs deliver what they should.

Mental Health: Children and Adolescents

Baroness Tyler of Enfield Excerpts

Wednesday 16th November 2016 Lords Chamber

Asked by

[Baroness Tyler of Enfield]

To ask Her Majesty’s Government what is their response to the Report of the Values-Based Child and Adolescent Mental Health System Commission What Really Matters in Children and Young People’s Mental Health, published on 7 November.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, we welcome the noble Baroness’s report and its endorsement of the direction set out in Future in Mind, our own report which puts children, young people and their families at the centre of this Government’s ambitious transformation programme to improve children and young people’s mental health and well-being. This means listening to their views and enabling them to access the high-quality care they need. This report builds on and strengthens that approach.

[Baroness Tyler of Enfield (LD)]

My Lords, I thank the Minister for his response. Does he agree with one of the key recommendations of the commission’s report that schools, if properly funded and supported, have the potential to make a really big difference to improving children’s mental health, not least because children spend one-third of their time in school? Linked to this, does he also agree that the proposed Prime Minister’s challenge on children’s mental health should incorporate this strong focus on schools?

[Lord Prior of Brampton]

My Lords, when I read the noble Baroness’s paper over the last couple of days, I thought the part about schools was the most persuasive. School is clearly critical. The pilot project being done by the Department of Health and the Department for Education, trialling the single point of contact in schools, is very important, as is the PSHE guidance on teaching about mental health at the four key stages of education.

NHS: Health and Social Care Act 2012

Baroness Tyler of Enfield Excerpts

Thursday 8th September 2016 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I congratulate the noble Viscount, Lord Hanworth, on securing this vital debate. The starting point for our debate is the impact of the 2012 Act—legislation which is etched on the memory of many in this Chamber, and I suspect none more so than the noble Lord, Lord Lansley, who has just spoken. It was the first Bill I was actively involved in after joining this Chamber and, my goodness me, it felt like a baptism of fire. It is fair to say that it was a highly charged and contentious piece of legislation. However, rather than rehearse the heated arguments again, today I will focus primarily on how the system has responded to the changes and what it means for the future.

We probably all agree that there is no appetite for further structural reform, and I doubt whether there will be in the years ahead. Therefore, the current immense problems of sustainability will need to be resolved within the current architecture. This will require huge ingenuity, creativity, cultural and behavioural change, and transformed styles of leadership at both national and local level, along with very different financial incentives.

As we have heard, the 2012 Act introduced major structural changes—I am not going to run through them again—but how has the system responded to these changes in the face of huge financial and operational pressures? To answer that question it is important to highlight some key factors. First, whatever their rights and wrongs, the geography of clinical commissioning groups is not strategic. Simply put, there are considerably more CCGs—some 209—than there are hospitals, of which there are just over 150. That is not helpful. Such fragmentation militates against strategic planning and decision-making.

Secondly, the more market-based system that competition and the introduction of foundation trusts by successive Governments heralded may have been okay during times of plenty, but during a period of unprecedented austerity, coupled with a major growth in demand, it has proved much harder to sustain. Each trust fights hard to protect its own position, making collaborative working and the significant shifting of resources much harder.

Thirdly, in practice it has proved very hard for GPs to undertake the role envisaged for them of fundamentally reshaping the services provided by hospitals for the benefit of their patients. Too often they have been overwhelmed by rising demand, making effective collaboration between GPs and hospital consultants, which can be hard at the best of times, a distant dream.

The simple truth is that there is not enough money in the system to do all the things being asked of the health and social care system at a time of rapidly rising demand from a growing and ageing population—and that is before we come to the newest policy goal of seven-day working. We would all like to see that in an ideal world, but it must be properly resourced and planned if it is ever to become a reality. The current approach of trying to ram it through on resources that are not really adequate for five-day working, let alone seven, is clearly not viable.

There has been no shortage of recent reports demonstrating the parlous state of NHS finances. Reports from NHS Improvement, the King’s Fund, Nuffield Trust, the Public Accounts Committee and others have all shown rapidly declining financial performance and an alarming scale of deficits. In short, the NHS ended 2015-16 with an aggregate deficit of some £1.85 billion—a threefold increase on the previous year and the largest deficit in NHS history.

It is not at all clear how the £22 billion funding shortfall by 2020 will be achieved. When resources and demand are so out of kilter, what is urgently needed is a system-wide response, with system-wide thinking at its very core. This means putting far greater emphasis on geography—or place-shaping, as it is sometimes called—and, in essence, thinking in terms of local health economies rather than in terms of individual institutions or bricks and mortar. That system-wide thinking needs to be based on trust, collaboration, innovation and sophisticated networking—in short, the key ingredients of a joined-up response.

In fairness, the Five Year Forward View—widely regarded as an excellent document setting out a long-term vision—coupled with the planning guidance are both attempting to do just that. We have recently had the introduction of the five-year sustainability and transformation plan, which highlights the need for systemic leadership and a truly place-based plan, with local leaders, including from local government, coming together and developing a shared vision of what will work best for the local community.

This is a welcome shift in emphasis towards collaboration rather than competition in the way NHS services are planned, even if it is being done somewhat by stealth. It also provides a much-needed opportunity to plan for a health service focused far more on people living in the community with long-term conditions rather than on treating illness in hospitals.

The country is divided into 44 sustainability and transformation footprints, as they are being called. Getting the geography right is essential, and they should have the strategic scale to look at major reconfigurations of services, including shifting resources from the acute sector into primary care, community care and, critically, social care—something that the smaller CCGs clearly struggle to do.

The approach feels right if the focus can be on far greater integration, collaboration and system-wide thinking. It is a real concern that the general mood music around these plans, due to be published in October, is negative at the moment. We have had reports of excessive secrecy, lack of local engagement and a strong emphasis on preventing immediate financial collapse at the expense of proper long-term thinking and planning towards long-term sustainability.

A recent statement from the chief executive of the King’s Fund, commenting on the plans, was blunt. He said:

“Almost all the additional funding provided by the government this year is being used to reduce deficits in acute hospitals, leaving little if any to invest in services outside hospital. Sustainability and transformation plans will not be credible unless they demonstrate how money and staff for these services will be found”.

Similarly, a recent Nuffield Trust report concluded the same thing. It had in it the memorable phrase that we would have to “preserve the NHS in aspic”—meaning having to halt any further advancement in healthcare quality and new treatment.

The final sentence of that report reads:

“The political acceptability of that—following a Brexit campaign which highlighted a potential £350 million for the NHS a week—is highly questionable”.

That is putting it mildly. We must have an honest debate which recognises that the service transformation needed for a health service fit for the future will take much longer than one Parliament, must be properly resourced, even if that means raising extra taxation, and, critically, have the financial incentives which encourage and reward collaboration and system-wide thinking. Otherwise we will simply limp from one crisis to another, and that is to no one’s benefit.

NHS and Social Care: Impact of Brexit

Baroness Tyler of Enfield Excerpts

Thursday 21st July 2016 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I too thank the noble Baroness, Lady Watkins, for securing this very important debate. Indeed, I cannot think of a more pressing and urgent subject on which to finish our sitting.

As we have heard in the debate, the UK’s vote to leave the EU will without doubt have major implications for health and social care, not least because it has ushered in a period of major economic and political uncertainty at a time when the health and care system faces huge operational and financial pressures, as we have debated so many times in this Chamber. The NHS faces an extremely challenging set of circumstances. Demand, particularly from our ageing population, continues to grow faster than funding, putting further pressure on an already strained service. Fundamental change in how we provide care is urgently needed if the NHS is to be successful in meeting the twin challenges of providing high-quality services while balancing the books. To do this it is vital that we have the right numbers of staff with the right skills in the right place, and ensure that they feel valued, welcome and engaged in the work that they do—hence the debate we are having this afternoon.

The EU’s policy of freedom of movement coupled with mutual recognition of professional qualifications within the EU means that many health and social care professionals working in the UK come from other EU countries. I know we have already heard these figures but it is important to emphasise that these are big numbers. This is not something at the margins: it is 55,000 of the NHS’s 1.3 million workforce and some 80,000 of the 1.3 million workers in adult social care.

As we have heard this afternoon, the NHS is struggling to recruit and retain permanent staff. Indeed, there was a shortfall of some 6% in 2014 between the number of staff that providers of healthcare services said they needed and the number in post, with particular gaps in nursing, midwifery and health workers. As we heard very powerfully from the noble Baroness, Lady Howarth, similar problems exist in the social care sector. I will not repeat those numbers but I am particularly worried about the very high vacancy and turnover rates in domiciliary care services, which provide care to some of the most vulnerable people—the elderly and the disabled—in their homes. Given the current shortfalls in both health and social care that we have heard about, surely the Government must urgently clarify their intentions on the ability of EU nationals to work in health and social care roles in the UK, not least to avoid EU staff in the NHS deciding to leave to work in other countries where they may feel that they are made more welcome.

Initially in the days after the referendum, it sometimes felt as if all EU nationals were being used as pawns in a negotiating game, and that was quite wrong. Since then, we have heard slightly more reassuring statements from Bruce Keogh, NHS England’s medical director, and Jeremy Hunt, the Secretary of State, who has sought to assure European staff working in the health service. We have also heard Simon Stevens call for more assurances, which are needed, and that is the right thing to do. However, we need to go a lot further. Providers of NHS and social care services must be able to retain the ability to recruit staff from the EU when there are not enough resident workers to fill vacancies. As others have suggested, this could be done by adding specific occupations to the Migration Advisory Committee’s shortage occupation list, which currently enables employers to recruit nurses and midwives from outside the European Economic Area. What steps will the Government take on this front?

I want to say a brief word about nursing staff. I am very conscious that I do not have anything like the expertise that we are so lucky to have in this Chamber in the noble Baroness, Lady Watkins, and, of course, the noble Baroness, Lady Emerton. However, I acknowledge the huge contribution that EU nurses make to the vital work of the NHS and, indeed, the health of the nation. Currently, some 33,000 EU nurses are registered to work in the UK. There has been a very large rise in this number since 2010. These numbers show that the UK has an ever-increasing reliance on nurses from the EU, who plug serious gaps in the nursing workforce. This is due to government cuts since 2010 to nurse education commissioning in the UK, which has drastically reduced the supply of nurses coming into the system. There will be serious consequences for patient care if EU health professionals are forced to leave the country or, indeed, are made to feel unwelcome and so decide to leave.

It is often the personal anecdote that brings this situation home. Yesterday, I had a very long day—about 15 hours—with my mother in a central London hospital. She is very elderly and frail and she needed an operation. But during that long day all her other complicated care needs had to be dealt with. The nurses in the hospital clearly came from all over the world. I cannot thank them enough for the care they gave my mother during that long and difficult day. It is absolutely clear to me that the NHS simply would not be able to function without staff from other countries; we just have not invested enough to grow our own. It takes four years to commission extra places and train nurses; it is not something that you can do overnight.

Where does all this leave us? I have to be honest and say that it leaves me feeling quite gloomy. I recently read a very good article in the Guardian, written by Richard Vize. He said that:

“The most insidious effect of the current anti-European climate will be to discourage EU talent from working in our health and care system”.

He went to say—and I think that this is the critical point—

“It is not just a question of the rules about who can work here, but the perception. With social and mainstream media in Europe already reporting incidents of racial abuse and a more general anti-immigrant feeling, and uncertainty about the future legal position of living and working in the UK, talented people from other EU nations have good reason to consider alternatives. There is a chronic global shortage of clinical staff, so the UK is part of a worldwide marketplace for talent. We have just made it more difficult to attract the best”.

It gives me no pleasure to say so but, frankly, I could not agree more.

I usually like to end on a fairly upbeat or positive note, as I know the noble Lord, Lord Crisp, does. He managed to do so extremely well, as always, but on this occasion I have failed. I end by raising an issue that the noble Lord, Lord Bilimoria, also mentioned. It is about that lie—that most flagrant and disgraceful lie—of the leave campaign. I have to say that there was very stiff competition for that particular accolade, but it is the lie where we were told that £350 million extra per week would be available for the NHS—it was plastered all over the campaign buses. Then of course it was retracted, even before the ink was dry on the results. But the public, quite understandably, now have an expectation that NHS spending will rise after the UK leaves the EU. I have never been very good at maths but I just made a little calculation. It is four weeks now—to the day, I think—since the referendum, so my calculation tells me that, four weeks on, £1.4 billion is now owed to the NHS. Can the Minister tell us whether that money has yet been received and, if not, how quickly he expects that money to be in the Department of Health coffers?

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.