Mental Health Services

Earl of Listowel Excerpts

Wednesday 25th February 2015 Lords Chamber

Asked by

[The Earl of Listowel]

To ask Her Majesty’s Government what plans they have to improve mental health services for infants, children and young people, for care leavers, and for adults with care experience.

[The Earl of Listowel (CB)]

My Lords, I am delighted to have this opportunity to discuss the mental health needs of children and young people in care.

I am grateful to the people I have worked with—the young people who are in care and leaving care who have shared their experiences with the parliamentary group; the clinicians, academics and practitioners who have made time to talk to me; and all those who have equipped me to speak to noble Lords today. I am grateful, too, for the lessons I have learnt from MPs who have chaired the parliamentary group for young people in care or who have campaigned in the area. They include former MP Hilton Dawson, Timothy Loughton MP, Edward Timpson MP, Craig Whittaker MP, Ann Coffey MP and the late lamented former MP Paul Goggins.

I have learnt that a cornerstone for mental health is to be able to make and keep relationships, and that family breakdown can destroy or impair that ability. Much of our job in repairing the mental health of abused or neglected children is to provide them with an opportunity of at least one enduring, consistent and benign relationship. Ten years ago, the charity Voice consulted young people on a blueprint for the care system. The children told us that they wanted one adult who would consistently follow them through their experience of care. They called him the Big Friendly Giant, after a character by Roald Dahl.

I hope that many of your Lordships present may attend future meetings of the all-party parliamentary group for children and young people in care. I know that it would mean a lot for the 60 or so young people who visit us each couple of months to see your Lordships there. There you will hear how young people have valued their relationships with foster carers, social workers and teachers. You will also hear children speaking of having more than 20 placements of fostering or more than five different social workers in a year and a half. From the care-experienced adults, you may hear from successful broadcasters who still see their social worker for tea today, or family men who now visit their children’s home to celebrate the manager’s birthday.

I am always pleased to hear the Minister say that he recognises the importance of an infant’s attachment to his mother. When key relationships fail, young people need to find someone else to be that reliable parental figure. A clinical psychologist, Sylvia Duncan, recently described the process of trauma in a seminar for the Institute of Recovery from Childhood Trauma. Many of us experienced trauma as a child—the loss of someone we love, a serious illness, even perhaps sexual harm. In the context of a loving family, where the trauma is not repeated, where one has not been betrayed by someone one trusts, where one can speak immediately about the trauma, recovery may be quick and leave no scars. Where the harm has been undertaken by one who one trusts, where that harm is repeated over years, where there is no one to discuss the harm with, serious trauma of the kind most young people entering care have experienced results.

Therefore, the finding of the Office for National Statistics survey of the mental health of looked-after children from 2003 should not have been a surprise. Mental disorders in children among the general population stand at 10%, half of which are conduct disorders. In the care population overall, 45% have a mental disorder and 37% of those are conduct disorders. In residential care, 72% have mental disorders and 60% of those are conduct disorders.

What does this mean for the experience of those working in children’s homes and foster care, and for adoptive parents? I will try to describe it. One may be caring for a strong, tall and beefy 15 year-old boy. Yet, for weeks or months, he may behave like an infant. He may not be prepared to leave his bed, may never show any gratitude for help given, may never clean up in the kitchen, and may not wash himself or cut his fingernails. Over time he may move towards his chronological age. Then one may be faced with rages from nowhere, with the fear that he may throw himself under a train when he next leaves the house, or that he may attack oneself or another child. One may be worried that he could set fire to the building.

Should the child be a girl, one may be worried about her sexual exploitation by men—although that might also be a concern for a boy. All this may leave one feeling bitterly resentful against the child; after all, he is 15 years of age. How can any trauma justify such selfish behaviour? One might say: “Next time he misbehaves, I will call the police, exclude him from the home, shout at him and see how he likes it, give him a slap in the mouth, the little wretch”.

This is where clinical group supervision is so important. Residential workers and foster carers need a space where they can vent the frustration, anger, fear and despair they feel about the children they work with. They need a clinician who can remind them that the child has regressed to an earlier stage of development, remind them how lonely and bereft that child is, and remind them that the most important thing that they can do for that child is to be reliable and tolerant, and continue to care. Without such support, carers are likely to burn out, quit, emotionally withdraw, or possibly even—we know this happens—attack the child. The most important thing for the recovery of that child is that there is nothing he can do to break the relationship with his carer.

It is therefore vital that the Minister is involved in ensuring that staff in children’s homes receive regular supervision or consultation from an appropriate mental health practitioner. I am very disappointed that in neither the guidance nor the new quality standards does there seem to be a stipulation on this. The psychiatrists who gave evidence to the noble Lord, Lord Warner, for his report on children’s homes in the mid-1990s advised that such an ongoing relationship with a mental health professional was the norm on the continent. Yet I am advised that this multidisciplinary approach may be applied in only about half our homes, even today. Does the Minister agree that such supervision or consultation is necessary? If so, what means will he use to see that it is implemented uniformly? I suggest that some of the payment for this—perhaps 50%—should come from the Department of Health.

A great deal of good work has been undertaken by this Government on reforming residential care. Serious consideration has been given to staff qualifications and staff are now better qualified. I commend the education Minister Edward Timpson MP, his predecessor Timothy Loughton and their officials on what has been achieved in a very difficult financial climate. However, I would urge whoever is responsible in the next Government to push further on qualifications as soon as possible.

If one of your Lordships’ children was deeply troubled and you were seriously troubled about their health and whether they would self-harm, would you wish to put them in the care of staff required to have only one A-level qualification? Would it satisfy you that the managers of these homes are required to have only a foundation degree—one year of higher education? The contrast with the continent is stark. There the status and qualification of staff is higher, yet they care for less challenging children.

Professor Berridge’s research on staff training is oft quoted by those who prefer the status quo. Yet in his recent blog for the NSPCC he emphasises the challenges of residential care, particularly in the light of the Rotherham experience, and the need by the next Government to raise the professional status of these people by raising the required qualifications.

Much of what I have said applies equally to foster care and adoption. While their children might be less trouble if they are with them 24/7, excellent social work support for foster carers and adoptive parents is vital, and I am grateful for the Government’s additional funding to support work with fosterers and adopters; and to my noble and learned friend Lady Butler-Sloss for her committee’s work in achieving this. Much training is offered to foster carers; consultation to groups of foster carers is rarer, but should be the bread and butter of specialist looked-after CAMHS. Access to individual therapies, including child psychotherapy, is important. I much look forward to the report of the taskforce that the Government have set up, due in March; I hope that it might refer to these therapies.

The last meeting of the parliamentary group discussed access to CAMHS for young people who are care leavers. We heard from one young woman who faced long delays in beginning therapy, and met her therapist once and only once because she was about to turn 18. A group of about 50 young people from all parts of England voted on the move from a 15 to a 25 year-old CAMHS service. All but one supported it. The Tavistock and Portman NHS Trust currently provides such a service to all young people. How is the Minister addressing the transition from child to adult mental health service for care leavers?

Finally, the Royal College of Psychiatrists points out that we can prevent so many children being taken into care each year by investing in parenting programmes. Does the Minister recognise the value of such programmes in keeping children out of care? So much good work has been undertaken by this and the previous Government on the education of looked-after children. I very much hope that in future, Governments will give as much attention to the mental health of looked-after children as to their education. I look forward to the Minister’s reply and to the contributions of your Lordships.

NHS: Financial Tariff for 2015-16

Earl of Listowel Excerpts

Wednesday 4th February 2015 Lords Chamber

[Earl Howe]

My Lords, it would require a full-scale debate for me to lay out in full all the things that we are doing to promote parity of esteem in the health service. The noble Baroness is right that in certain parts of the country there has been acute pressure on bed numbers, but bed numbers have been increased in some of those areas, and NHS England is paying close attention to the need to ensure that those who need in-patient treatment receive it.

[The Earl of Listowel (CB)]

My Lords, will the Minister look carefully at the bureaucratic burden on clinicians? A number of clinicians have raised with me the fact that there is too heavy a burden, and that because of that burden, they are not being as efficient as they might be.

[Earl Howe]

My Lords, yes of course the bureaucratic nature of commissioning needs to be minimised and we do all we can to achieve that. However, the need to ensure that we make a careful distinction between commissioners and providers does, I am afraid, mean that rather a lot of numerical work has to go along with that and, as is right, discussion between commissioners and providers to ensure that the system works smoothly.

Mental Health Services

Earl of Listowel Excerpts

Wednesday 26th November 2014 Lords Chamber

Asked by

[The Earl of Listowel]

To ask Her Majesty’s Government what plans they have to improve mental health services for infants, children and young people in local authority care, and for care leavers.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, in August 2014 the Government established the children and young people’s mental health and well-being task force, which is looking at how to improve access to services that are more responsive to children and young people’s needs. It has a particular focus on the needs of the most vulnerable children, including care leavers and those in local authority care.

[The Earl of Listowel (CB)]

I thank the noble Earl for his Answer and for the work of the task force, which is most welcome. Is he considering encouraging the systemic approach to supporting foster carers and staff in children’s homes, whereby clinicians support groups of staff in children’s homes and foster carers? This can be a very effective way of making use of scarce CAMHS resource. Will he also look at undertaking another, very thorough, survey of the mental health of looked-after children? The last very thorough examination of their mental health was carried out in 2002, and it would seem that it is time to look again at their mental health issues.

[Earl Howe]

My Lords, on the noble Earl’s second point, yes, a survey is most certainly being actively considered. On his first point, he is absolutely right. One of the task force’s focuses will be to consider and make recommendations on how we can provide more joined-up, more accessible services built around the needs of children and young people, looking at sometimes innovative solutions about how to get there and how to improve access to health and support across different sectors, including in schools, through voluntary organisations and online. I am very encouraged by the task force’s terms of reference.

Health: Mental Health

Earl of Listowel Excerpts

Tuesday 28th October 2014 Lords Chamber

[Earl Howe]

My Lords, investment in mental health research by the National Institute for Health Research has nearly doubled over the past four years from £40 million in 2009-10 to £72 million in 2013-14. I hope that the noble Lord will take from that that we put a priority on this. Of course, it is very important that local authorities do not downplay the significance of mental health. We have made it very clear that disinvestment is not an option for them. We are discussing with local authorities this very issue.

[The Earl of Listowel (CB)]

My Lords, will the Minister seek to encourage the very good practice of a few areas in providing a seamless service for young people leaving public care from the age of 16 to 25 or 14 to 25 so they get the mental health support to allow them to be successful in adulthood? Does he recognise that effective mental health services for children will much diminish the demand in adulthood?

[Earl Howe]

I agree with the noble Earl. On 20 August the Minister of State for Care and Support announced a new children’s task force to look at all aspects of child and adolescent mental health services and how best to improve outcomes for children with mental health problems. Its remit includes an investigation of how access across the whole of children and young people’s mental health services could be improved. The task force will report in the spring of next year.

NHS: Midwives

Earl of Listowel Excerpts

Monday 17th March 2014 Lords Chamber

[Earl Howe]

My Lords, I agree that in certain parts of the country maternity services are under pressure, but it is encouraging that the ratio of births per midwife has improved nationally. Indeed, since 2010 the number of midwives has increased by 4% and the number of births by 1%. However, the noble Lord is right to attach importance to mental health services. Improving diagnosis and services for women with pregnancy-related mental health problems is one of the Department of Health’s objectives for maternity care. That is why Health Education England has been tasked with working with partners to ensure that pre-registration and post-registration training in perinatal mental health is available to enable specialist staff to be available to every birthing unit by 2017.

[The Earl of Listowel (CB)]

Is the Minister aware of the excellent model of best practice at Chelsea and Westminster Hospital, where there is a mental health team working hand in hand with the midwives, and how important that is to retention? Is the supervision of midwives being looked at—whether they feel well supported and wish to carry on in the profession because they have a mentor who can support them?

[Earl Howe]

I thank the noble Earl for bringing the example of the Chelsea and Westminster to my attention. I am sure it is a model of good practice, as I know how good that hospital is. With regard to supervision, the noble Earl is right. This bears upon the whole question of midwife numbers, to ensure that we have enough midwives not only looking after women about to give birth and giving birth, but also to ensure good practice in our hospitals and midwifery units.

Health: Midwives

Earl of Listowel Excerpts

Wednesday 5th March 2014 Lords Chamber

[Earl Howe]

My Lords, the Government are committed to improving the choice of place of birth for women, continuity of care for mothers and the experience of care that they have. There are now 1,800 more full-time equivalent midwives than in May 2010 and there is a record number—in excess of 5,000—in training at the moment. The most recent data from November last year show that the number of midwives has increased at twice the rate of the number of births—by more than 6% since May 2010. We know that we need more midwives in the service but they are coming down the pipeline.

[The Earl of Listowel (CB)]

My Lords, is the Minister aware of the Australian research which suggests that the NHS could save £300 per birth if it adopted the one-to-one midwifery model? Might he consider how to encourage clinical commissioning groups and health and well-being boards to commission caseload midwifery? This has proved very effective in reducing the number of episiotomies and in encouraging, for instance, breastfeeding.

[Earl Howe]

My Lords, I am very interested to hear what the noble Earl says about the Australian experience. The mandate that the Government issued to NHS England, published in November 2012, states that women should receive better care during pregnancy and have a named midwife responsible for ensuring personalised, one-to-one care throughout pregnancy and childbirth, as well as postnatally. As part of that, we want NHS England to work with partner organisations to ensure that women are able to make informed and safe choices about where to have their baby. However, it is probably too soon to commit to a ratio of one midwife to one expectant mother.

Health: Meningitis B Vaccine

Earl of Listowel Excerpts

Monday 24th February 2014 Lords Chamber

[Earl Howe]

Our childhood immunisation programme generally bears comparison with any country in the world and is very extensive and very successful. However, the incidence and prevalence of meningitis B is higher than in many other countries, which is why there is such concern about it.

[The Earl of Listowel (CB)]

My Lords, will the Minister assure the House that, if this vaccine is accepted, the infrastructure will be in place to enable it to be administered swiftly to as many children as possible? Are health professionals trained and ready to administer the vaccine, if it is decided to accept it?

[Earl Howe]

The main practical constraint is manufacturing the vaccine. However, I assure the noble Earl that the NHS is well equipped to deliver the vaccine once it has it in its possession.

NHS: Mid Staffordshire NHS Foundation Trust

Earl of Listowel Excerpts

Monday 11th March 2013 Lords Chamber

[The Earl of Listowel]

My Lords, I am most grateful to my noble friend Lord Patel for calling this timely and important debate. As vice-chair of the parliamentary group for children and young people in care and leaving care, I am aware of some of the issues around caring for vulnerable people.

Indeed, in reading the Francis report, I recalled another report by my noble friend Lord Laming at the beginning of the past decade into the death of Victoria Climbié. A member of staff of Haringey social services said that they were providing a conveyor-belt service for children and families and were overwhelmed. The principal social worker for Victoria Climbié, Lisa Arthurworrey, was a young, inexperienced, newly qualified social worker with an excessive case load who was poorly supervised. Alas, she and her colleagues were not able to take the necessary steps to prevent the death of that eight year-old child.

In my experience, particularly of child and family social work and of staff in children’s homes, it is vital to value those who work directly with such vulnerable people and to provide them with the training and support they need to do the right job. If one wishes to create a culture of care, many factors are involved. However, a crucial element of that is providing a caring environment in which one takes care of and values one’s workforce. One needs to select the right people and offer good continuous professional development, including training and supervision, and ensure that the voice of that workforce is listened to. I was particularly pleased to see the Francis report emphasise this need for a strategy for the workforce. I was also pleased to note the detail regarding the regulation of healthcare assistants. I would be grateful to the Minister if he could say a little about progress towards registering these assistants. It is encouraging that there is now talk about registering staff in children’s homes. This has already happened in Wales and Scotland and plays an important part in protecting vulnerable people in those settings.

As for the vital necessity of caring for the workforce, I would be grateful if the Minister would indicate what more might be done to make more public the state of morale within the NHS workforce, including, for instance, easily accessible information on staff turnover and sickness and absence rates. Having read the Francis report, if I go into hospital the first thing I will try to find out is the state of staff morale in that hospital. In discussions on the Health and Social Care Bill, we were given information from the King’s Fund or the Nuffield Trust indicating the wide disparity in workforce morale in different trusts. This needs to be addressed if we are to change the culture to one of more consistent care.

Finally, and I say this hesitantly, my sense of what is sometimes the most dispiriting thing for people working in the health service, having spoken with them over the years, is the sense that there is another huge reform coming through. It can seem that each time there is a new Government or a new Secretary of State, there is a new transformation of the health service. Respectfully, therefore, I request that the Minister perhaps encourages his colleagues to think twice before embarking on any major new reforms of the health service. I would respectfully say the same thing to the opposition Front Bench. Given that experience of the concerns expressed in the past, I would be grateful if they would attend to that.

Carers

Earl of Listowel Excerpts

Monday 14th January 2013 Lords Chamber

[Earl Howe]

My Lords, the latest figure I have for carers from the census is that there are 5.4 million unpaid carers in England. The noble Baroness was right to mention the figure of £119 billion, although it is a figure we can argue about. It is probably an overestimate as regards the cost to public funds. However, she makes a very important point about employment. The Government fully recognise the importance of supporting carers to remain in work. The Department of Health has established a task and finish group with employers for carers to explore how to improve support for carers to remain in employment. Jobcentre Plus provides practical assistance for carers seeking work; in particular, it can offer practical support for all carers who are employed for less than 16 hours a week.

[The Earl of Listowel]

My Lords, is the Minister aware of the concern of many adult carers of children with disability at the number of changes in social workers that their child has, and how that undermines their ability to be effective advocates for these children, especially as they make the transition to adult services? Does the Minister monitor the number of changes in social workers supporting such families? How can we ensure that this important factor is improved upon?

[Earl Howe]

My Lords, the noble Earl makes an extremely important point about continuity of care. I am not aware that my department monitors the point that he raises, although it is one that we expect local authorities to bear closely in mind as they fulfil the criteria to be rolled out in the social care outcomes framework, which contains a strong strand relating to service user satisfaction.

NHS: Hospital Beds

Earl of Listowel Excerpts

Thursday 6th December 2012 Lords Chamber

[Earl Howe]

My Lords, as I mentioned earlier, NHS underspends are not lost to the NHS—they can be carried forward from year to year. But on his central point, I should make it clear that we are struggling to reconcile the Dr Foster bed occupancy figures with those that we have. Dr Foster has stated that bed occupancy is at a dangerous level, at over 90% for 48 weeks of the year. We are looking closely at that analysis and methodology, but we cannot agree with those conclusions at the moment, given that the department monitors the position on a daily basis during the winter and on a quarterly basis at other times. However, I agree with the noble Lord that there are too many people in hospital. We need to ensure that we move more care into the community. I do not see this as insuperable within the current budgetary expenditure limits.

[The Earl of Listowel]

My Lords, I want to ask about community midwifery services and avoiding bed use by that means. Is the Minister aware of the great value to children in terms of outcomes of promoting a good relationship between midwives and parents, increasing the rate of breast-feeding and reducing episiotomies? In his reconfiguration, when he is thinking about not using so many bed spaces, will he recognise the value of local community midwifery services?

[Earl Howe]

Yes, my Lords. That is the precise reason why there are currently 5,000 midwives in training, which is a record number. The noble Earl is absolutely right to identify the midwifery service as key to enabling children to get a healthy start in life and parents to ensure that children get into good eating and exercise habits.