NHS: Mental Health Services

Baroness Young of Hornsey Excerpts

Monday 8th October 2012 Lords Chamber

[Baroness Young of Hornsey]

My Lords, like other noble Lords, I thank the noble Lord, Lord Alderdice, for introducing the debate this evening. I am sure that we will all acknowledge that although some progress has been made in this area, there is still an awful lot of work to be done. No doubt we will return to this subject in the years to come.

I am very glad that the noble Baroness, Lady Tyler of Enfield, spoke so much about children and young people. This is a point that I, too, will make. She also raised the issue of the implementation framework for the mental health strategy for England. That is another area I will touch on this evening. As the noble Baroness stated, we need to do much more to build good mental health and resilience among children and young people from birth through to adulthood. At the other end of the scale we also need to address the challenges faced by an ageing population, with an increasing number of older people experiencing significant mental health problems, including but not exclusively dementia. As always, I am afraid that there is still a substantial job of work to be done to ensure that ethnic minority service users are treated fairly.

The content of the implementation framework has been well received. However, there is no statutory backing, and it is phrased only in terms of what local health and other bodies, including the voluntary sector, “might” rather than “must” do. At this time of severe spending constraints in the NHS, will the Minister explain how his department intends to ensure, first, that the NHS across England acts on the implementation framework; and, secondly, that non-NHS organisations, too, which are crucial to the success of the strategy, act on the framework? As the noble Lord, Lord Wills, mentioned, that will include ensuring proper support and proper mechanisms to enable the service to be of the highest quality.

An increasing body of evidence shows that children and young people can develop mental health problems from a very early age, and that these problems, if not addressed quickly, and effectively, have a higher risk of developing into adult mental illness. Most adolescent and adult mental illnesses can be traced back to childhood. Therefore, there is an urgent need to focus on children’s early years, for example through building parenting skills and providing support to vulnerable families with young children. In addition, schools have a crucial role to play in building children’s emotional well-being, especially given the link between mental health and academic achievement.

Although for clear reasons we focus on mental ill health, we should also look at how we understand mental well-being and how we can encourage and develop and make sure that that works, in order to pre-empt instances of mental ill health. I would like the Minister to acknowledge the importance of children’s and young people’s mental health, and outline the department’s proposals for increasing support for parents and families, particularly with young children, in vulnerable situations. I reiterate what the noble Baroness, Lady Tyler, said about children in care being at very high risk of developing mental ill health both while they are in care and subsequently.

The Mental Health Foundation project, Age Well, is a two-year inquiry funded by the Esmée Fairbairn Foundation. We have been looking at the factors affecting the mental health and well-being of the generation of people currently aged between 55 and 65—the so-called baby boomers—as they get older. I have been privileged to chair the panel of inquiry that will be publishing its report on this subject shortly. The rationale for conducting the inquiry was that people born between 1946 and 1955 are now growing older and moving into a life-transition period. Growing older, of course, brings challenges that are different from those faced in earlier phases of life.

Evidence shows that the experience of mental illness in later life is often underrecognised, underrated and inadequately treated. Risk factors for mental ill health for the cohort include bereavement, the disabling effects of chronic conditions, pain, the effects of being a carer, loneliness, social isolation and so on. Protective factors include—and this relates to mental well-being—social ties, connectedness, intimate relationships, friendship and engagement in social activities. Good self-esteem and self-reliance can also buffer people against difficulties.

A major factor in population ageing is survival against premature death; fewer people in the 1946-1955 group have died in childhood, young adulthood or middle age, but the evidence is that they may not be much healthier than previous age cohorts as they grow older. Inequalities have been growing in the UK population since the 1980s. This is shown in a range of outcomes, including experience of illness and poor mental health. There is a need to focus on protecting those who are most likely to be at risk for poor mental health and experiencing mental illness.

These are some of the key findings that we have uncovered and had witnesses speak to us about so far. We would like to be assured that the Minister and his department are fully aware of and are equipped to deal with the implications for our ageing population of mental ill health and promoting mental well-being.

The Mental Health Foundation and Age UK hosted an expert seminar earlier this year on mental health among older people. There were a number of key messages from that group. I am not going to go into them all now because there is a report available. However, there is no doubt that the NHS reforms have created a period of great uncertainty and that everyone interested in older people’s mental health needs to keep pressure on the reorganised NHS, public health and local authority bodies to work together to plan and commission a suitable range of support for older people.

Another crucial issue for the mental health services must be ethnic minorities’ experience of the mental health system; people of African Caribbean descent in particular are still being prescribed stronger medication, are more likely to sectioned, and, at least in London, are more likely to be referred to the mental health services by the police. Can the Minister tell the House about specific mechanisms for engaging with this issue and when we might expect to see some improvement in an area that has long dogged the mental health services?

EUC Report: Healthcare Professionals

Baroness Young of Hornsey Excerpts

Thursday 22nd March 2012 Lords Chamber

Moved by

[Baroness Young of Hornsey]

That this House takes note of the report of the European Union Committee, Safety First: Mobility of Healthcare Professionals in the EU (22nd Report, HL Paper 201).

[Baroness Young of Hornsey]

My Lords, domestic healthcare has been high on the agenda of this House for the last six months or so. As with most other policies, there is a European dimension. This afternoon I would like to draw the House’s attention to the mobility of healthcare professionals within the EU.

I am sure that noble Lords will be aware of the debate that took place in the House on 8 September 2011 concerning the disparities between EEA and non-EEA healthcare professionals, as moved by the noble Viscount, Lord Bridgeman—who subsequently joined my committee, I am very pleased to say. On 11 January 2012, a Question for Short Debate asked by the noble Lord, Lord Kakkar, touched on the mobility issues but also considered other EU measures such as the working time and clinical trials directives.

Since its inception in 1948, the NHS has relied heavily on overseas-trained nurses and doctors to bolster its workforce. Their contribution has been significant and, since our accession to the European Union, what began with legal migration under the Commonwealth has been superseded by legal migration from other European countries.

We launched our inquiry into the mobility of healthcare professionals in May, shortly before the Commission published its Green Paper on revising the professional qualifications directive. Our report was published last October and considered the operation of the directive as it relates to the healthcare professions that are covered by its system of automatic recognition. The report not only made a number of recommendations to the Government but acted as our response to the Commission’s Green Paper consultation.

From the outset, we supported the principle that the mobility of healthcare professionals can bring significant benefits to patients, professionals and the EU in general. None of our witnesses challenged this assumption. However, we also recognised that the current directive failed to command the confidence of patients and professionals. Major UK regulators including the General Medical Council and the Nursing and Midwifery Council expressed strong concerns in their evidence to us that discrepancies in the current system forced them to admit individuals who did not meet the standards otherwise required of UK or non-EEA professionals, thereby putting patients at potentially serious risk. Incidents related to the failures of the directive have been statistically low. However, high-profile examples have had fatal results. This has undermined confidence in the directive and led to fears in some quarters that mobility has been prioritised over patient safety.

We examined the minimum training requirements contained in the current directive and concluded that they were out of date and badly in need of updating in order to reflect modern practice. We also considered whether there should be more stringent requirements for professionals to undertake continuing professional development, and whether a more competency- based approach to training and professional development should be adopted. We examined how fitness-to- practise information was shared between competent authorities in each member state, and we were alarmed to hear that competent authorities often fail to share information and that in some member states there are a plethora of different competent authorities, causing added confusion.

We concluded that the use of existing mechanisms such as the internal market information system needed to be enhanced and become more routine, representing a simpler and more cost-effective way of improving information-sharing than the Commission’s favoured option of introducing a European professional card.

Communication between patients and healthcare professionals is vital, and everybody agreed that professionals must be able to communicate effectively in the language of the host member state. We believe that the directive fails to ensure this and needs to be clarified so that language testing is permitted at the point of registration if deemed necessary for patient safety by the relevant regulator.

In the report’s conclusion we reached the view that encouraging mobility should never be at the expense of patient safety and that this must be the overriding concern in all circumstances. We believe that the current directive strikes the wrong balance and therefore welcome the Commission’s review, and we call on all parties, including the Government, to act quickly to ensure that serious failings in the current regime, which places patients at unacceptable risk, are remedied. Such changes would not represent a barrier to free movement but would instead strengthen it by rebuilding confidence.

The Government’s response was published on 19 December 2011, the same day as the Commission’s proposal for a revised directive. There is clearly a lot of common ground between our views and the Government’s views on the issues that we dealt with in our report. The Commission’s proposal to revise the directive goes some way to remedying the shortcomings in the original directive that we identified in our report. An alert mechanism will be introduced so that regulatory bodies must warn each other if, for example, a doctor or nurse has been struck off or suspended from a register and attempts to register in another member state.

The minimum training requirements for healthcare professionals will also be updated to reflect modern practices, and regulatory bodies will be able to check the language skills of health professionals. However, there is some confusion here. On the one hand, the GMC says that it is not currently allowed to systematically test language skills. On the other hand, the Commission says that it is. The situation is clearly ambiguous and we call on the Government and the Commission to work together to achieve what seems to be a common goal: to achieve clarity on this crucial issue. The Government’s proposed amendments to the Medical Act should happen in accord with any changes agreed to the EU directive in this area.

We also welcome the proposed exemption of healthcare professionals from the partial access provisions, in the interests of patient safety. We note that with the support of the relevant professional bodies, the Government are intending to push for veterinary surgeons and architects to be exempted. However, we also note that the Commission’s proposal contains no reference to the importance of continuing professional development. We reiterate our report’s recommendation that it should include an obligation on member states to require healthcare professionals to undertake CPD, but without being too prescriptive, and leaving the detail to each member state’s competent authorities. Although we remain to be convinced of the merits of the professional card, we note that the proposal seems to suggest that the introduction of professional cards for different professions will not be mandatory.

Although UK regulators have welcomed the introduction of an alert mechanism, they have questioned why it should apply only to the automatically recognised professions and not to the general professions. They also stress that the mechanism should flag up any conditions, restrictions or limitations placed on an individual’s right to practise, rather than just removals from registers. We share their concerns in this regard.

Data protection concerns have been raised in regard to the proposed alert mechanism, including by the European data protection supervisor. We touched on that in our report and note that the Government are already alive to this issue. We hope that they can successfully address these concerns during the negotiations, particularly in the context of the separate proposals for a revised data protection directive.

We have not yet received the Commission’s response. However, since the publication of our report I have participated in two conferences in Brussels which have included health regulators from across Europe who are working closely together on the proposals for a revised directive. During each event, interest in and awareness of our report was high. It therefore provided an excellent opportunity to reinforce the EU Committee’s views on this matter. I would also say that there was a good deal of consensus around the table among healthcare professionals from across the EU.

I also had the pleasure of hosting a roundtable meeting with senior representatives of all the automatically recognised professionals in the UK—that is, doctors, nurses, midwives, dentists, pharmacists, vets and architects. I hosted this event on 26 January and their views have helped to inform the committee’s ongoing scrutiny of the Commission’s proposal. We know that the Government have already worked closely with UK regulators in an effort to reflect their concerns during the negotiations on the proposal, which we commend.

In conclusion, I hope that my remarks demonstrate that the impact of the committee’s work in this area, as well as its proactive stakeholder engagement, has been successful and resulted in an ongoing scrutiny rather than, as it were, writing a report and leaving it on the shelf. The committee hopes that all parties to the negotiations on the revised directive, which are likely to continue until the end of this year, will strive to achieve real and practical improvements to the draft provisions. I look forward to hearing from other noble Lords, and of course from the noble Earl, Lord Howe, on behalf of the Government regarding this important matter. I beg to move.

--- Later in debate ---

[Baroness Young of Hornsey]

My Lords, I thank all noble Lords who have taken part in today’s debate. It was heartening to hear so much consensus across the House on the issues that have been raised by the inquiry and in our subsequent report. As I said earlier, I was pleased that the noble Viscount, Lord Bridgeman, joined the committee after having initiated a debate about language. I am very grateful to him for his diligence in pursuing that issue. It has to be said that he also has a very well rounded view of the whole set of issues involved in this report, although his focus has been on language-testing and so on. I think we all want to see something unequivocal and unambiguous in relation to language-testing to which we can subscribe.

I am grateful, too, to the noble Lord, Lord Dykes, for helping to put the report in a wider context. That is important, as is flagging up the fact that we feel that mobility is a good thing. We benefit from it, as we have done for many years and will continue to do. The question is really how we make the balance between the desirability of mobility and patient safety work. Of course, the noble Lord is correct to point out that we are talking about a very low incidence of fatal and serious impacts arising from the mobility of inappropriate practitioners. By the same token, as I think the noble Viscount, Lord Bridgeman, said, one is one too many, and that is what we have to tackle. In fact, somebody brought to my attention another very worrying incident concerning a doctor who has left a trail behind him on mainland Europe. Therefore, we have to be vigilant on those issues.

The noble Baroness, Lady Thornton, again emphasised the issue of benefiting from free movement. It can sometimes be easy to lose sight of that when we discuss and focus on what are, essentially, problems. I am glad that she raised continuing professional development, which the Minister picked up and went into in some depth. Again, many of us would agree that it is an absolutely crucial area.

During our evidence-taking, we heard the example of someone from outside the UK who had trained as a midwife 20 years ago and had no professional development subsequent to that. That is an area in which there have been lots of advances in many different ways. The idea that someone who first trained 20 years ago and has not practised since could come into midwifery here is quite disturbing. Therefore, CPD is very important.

I will not pick up on everything; it has been a long day. I will just deal with the professional card, which is another area on which we agree. It is interesting to note that at the conference called by Healthcare Professionals Crossing Borders in Brussels a couple of weeks ago, that was something of which some people were in favour while others had deep concerns about it.

I should also say that most people at that gathering had deep concerns about language. It is not only us who have these anxieties about how and at what point we test language. Part of the problem is that the complexity is there anyway but there are other layers of complexity to do with all the different systems that are in place in different member states. There are even different ways of thinking about registration. Some member states separate registration from licensing, which we do not. Therefore, if we say that something can come into play at the point of registration, it will mean something different in different places. All that complexity means that it is even more crucial that we have absolute clarity and push forward.

I reiterate how pleased I am that there is so much consensus on the areas in which we need to make progress, and that the Government are taking up those areas and working with organisations such as the GMC to ensure that we maintain and enhance a balance between mobility and patient safety.

In conclusion, it is absolutely right for me to acknowledge the unequivocal pleasure and delight of working with Sub-Committee G and my colleagues on it, who are represented today by the noble Viscount, Lord Bridgeman. We worked very hard on the report, as noble Lords can see. We did a lot of questioning and reflecting, which paid off in producing a report that many people have referred to. When I go to meetings in Brussels and elsewhere, people brandish copies of the report, which is heartening to see. I also thank the staff, particularly Talitha Rowland and Alistair Dillon, for their work on the report.

The debate today has, typically, been very informative and well informed. It points to the ways in which different parts of the House and our society can work together to ensure that we achieve the balance that we all seek. I beg to move.

Motion agreed.