Health and Social Care Bill

Debate between Lord Alderdice and Baroness Whitaker

Wednesday 2nd November 2011 Lords Chamber

[Lord Alderdice]

My Lords, I am grateful to the noble Baroness, Lady Hollins, and the noble Lord, Lord Patel of Bradford, for bringing these amendments forward. I have been happy to put my name to them—and I thank the noble Baroness, Lady Finlay of Llandaff, who very graciously withdrew her name in order that I could show my support for the amendments.

Like the noble Baroness, Lady Hollins, I am a fellow of the Royal College of Psychiatrists, albeit I am a recently retired psychiatrist. I would like to support these amendments, but coming from a slightly different perspective from some other noble Lords. When I came into psychiatry many moons ago, we learnt that some 50 per cent of all hospital beds in my part of the United Kingdom were mental hospital beds. That is no longer the case, because there has been a great move towards community care—or at least having people with mental illness in the community, which is not always the same thing. It has many advantages, but one disadvantage is that people have lost a sense of the size and severity of the problem. They tend to think of mental illness as a bit like cancer or diabetes, or something of that kind—as another disorder, along with all the rest. But it is not; it is something quite different.

Whenever any of us suffers from a physical illness, it feels like something that has happened to us that we have to respond and react to. But when something happens by way of a mental illness, what is attacked is our very selves, because having mentation is what it is to be a sentient, conscious, reflective human being. I am not talking about people feeling a bit down or depressed or reacting to circumstances or difficulties; I am talking about mental illness. Those differences have sometimes been misunderstood and forgotten, including by psychiatrists in recent years. What disappears, what is attacked and what is under pressure is the very thing that makes you a human being.

One case in which that is most commonly seen is dementia. When my grandfather died and I was consoling my mother, she said, “John, my father died two or three years ago. It was only the shell that passed away yesterday”. In truth, the person is gone. That does not mean that we do not care for the rest, but the person has gone. Whether it is an organic disorder, or an organic-related disorder like dementia, or a psychotic disorder such as progressive schizophrenia, or even a neurotic disorder such as obsessive compulsive disorders and anxiety states, it attacks what it is to be a human being. It is a very different thing. All sorts of aspects of the being are attacked—the volition, the will, the capacity to want to do things, disappears. The capacity to care for the rest of the self is often attacked. This means that the very kind of service that you have to provide for people with serious mental illnesses is quite different. Whereas it might be legitimate to say of many physical illnesses that we expect the person to come along and to understand that they have to make a bit of an effort, with someone who has a serious mental illness, whose very capacity to understand and to care for themselves and address those kinds of things, they are attacked by the illness itself, and that expectation must be modified and be quite a different thing.

That leads me to be very supportive of the notion in the noble Baroness’s amendment, which I share with her, that in the health service we need to understand the differences as well as the similarities and crossovers between mental and physical illness. Noble Lords have said that they have some optimism that the stigma is less of an issue now than it used to be, and they hope that we might get to a point where it will disappear. I am somewhat of a sceptic about that, because I think that there is something fundamentally different about having a physical illness, when you can feel the lump or the bump and reassure yourself, and mental illness, when frankly at times all of us have some uncertainty about our own stability in that regard—and with good reason. It provokes a very understandable anxiety about the very existence of the self, which means that there will always be a degree of fear about it that does not necessarily exist in physical disorders. I am always encouraged when people become more understanding, of course, and I am always encouraged by opinion polls that say that that is the case, but I retain a little uncertainty that we are really there.

When I was training I used to come over from Belfast to the Royal Free Hospital in London for supervision every month. Sometimes the consultant was not ready to see me, so I would sit down among the patients in the clinic. I remember when the consultant came out one day and said, “I’ve decided that you’re really quite stable, John”. I said, “I’m sorry, what do you mean—why on earth have you decided that?”. He said, “You don’t seem to have any anxiety about sitting among the patients in the psychiatric clinic”. The truth is that many of us have those kinds of anxieties. It is a different thing.

When it comes to service provision, there is a greater tendency to ignore, forget and set aside the need for the resources for people who are suffering with mental illnesses. One of my concerns, as we move into a time of increasing austerity—and I suspect that will be the case for quite a period of time—is that there will be a temptation to focus on those services where patients can be demanding, emphasise their needs and promote the requirements that they have. Those who suffer from mental illnesses will find themselves shying away and not necessarily having the provision for it. Therefore, to put on the face of the Bill that the responsibility is for people with mental illness and physical illness is an important preventive factor for the next number of years—we can easily judge them to be years—of financial and economic pressure.

It is not just that kind of pressure that exists. Over the last number of years, I have noticed with many of my colleagues in psychiatry that there has been a tendency to slip back towards the provision of care for those who have psychotic illnesses or organic mental states and to try to forget about those with neurotic disorders who may sometimes be dismissed as the walking wounded. They are severe debilitating disorders that destroy lives and damage families and relationships, but many do not get the attention now that they should. Putting it on the face of the Bill would help to keep it in people’s minds.

We are not necessarily talking about disturbances of personality. It is a different kind of a matter. I hope that when the Minister comes to reply he will understand that this is not merely a question of the needs of a particular section of the community or a particular disorder or group of professionals. It is about a particular aspect of being a human being, which affects all of us, inside and outside this House, and is extremely important for our health service to recognise and have always brought to its recognition—whether through the Secretary of State, referred to through Amendment 11, or the National Health Service Commissioning Board, referred to through Amendment 106, or at the level of a clinical commissioning group, referred to through Amendment 180. The issue is not with the precise amendments but the precise problem, which I hope that my noble friend the Minister will be able to reassure us upon.

[Baroness Whitaker]

We have heard very powerful arguments from all sides of the House in support of these amendments, from deep and distinguished professional expertise, which in turn is backed by the professional institutions. I know the Minister will want to pay heed to that.

I would like to offer a lay view. These amendments would redress a deep imbalance. The Minister may well say again, as he did in his letter to Peers who spoke at Second Reading, that the Government's good mental health strategy,

“makes clear an expectation of parity of esteem between mental and physical health services”.

And so it does. But that is not the same as making it happen.

The Minister may point out again,

“in law, the term ‘illness’ covers all disorders, both physical and mental, so it is perfectly adequate for any Act of Parliament to refer succinctly to ‘illness’”.

The trouble is that however enlightened the intentions in the strategy, and whatever parliamentary draftsmen may say, we live in a culture which has for centuries relegated mental illness to the realm of the weird, the unmeasurable and the stigmatised, as others have said. Even after the great advances of the last 150 years, neither the resources applied nor that general public understanding which supports political action is remotely adequate for a realistic approach.

What I have seen is that bouts of mental illness severely erode the ability to cope with the problems that life throws up. They do not mean that the sufferer has to be treated like a being apart but they crucially impair the ability to earn a living. How many of those with chronic mental illness hold down a job? They can irreparably destroy relationships, which I heard a lot about when I was on the board of the Tavistock and Portman NHS Foundation Trust, and as a consequence of this combination the sufferer often loses their home. This is devastating; it is arguably more serious than many physical illnesses in its consequences.

When I used to volunteer for Crisis at Christmas, probably over half the homeless people I met were mentally ill. Dedicated professional volunteers came and attended to their coughs and colds, their teeth and their toenails. They sewed their buttons on and gave the heroin addicts methadone but there was never even the most limited talking therapy. I have had colleagues who have kept their proneness to clinical depression secret, even when medication controlled it perfectly adequately, out of fear for the career consequences, and others whose alcoholism was treated as only a disciplinary matter—contrast that with diabetes or severe allergies. This damaging general culture can be changed only if there are enough professional resources to make an impact on it and if there is no excuse, by means of the words—or lack of them—in the statute, to treat mental illness less seriously than physical illness.

How is it that, in answer to the Question which my noble friend Lady Thornton asked on 3 October, the Minister was able to say that the Churchill Medical Centre, a GP practice, deregistered 48 patients with dementia and mental disabilities,

“due to the resources required to support those patients”?—[Official Report, 3/10/11; col. WA 102.]

Are patients deregistered because they have asthma or congestive heart disease? I think not. Osteoporosis units are funded—good—but local psychotherapy units, which so often have to deal with the residue left by more superficial, short-term and cheaper treatments, are not. Cognitive behaviour therapy, excellent for some purposes, is so widely offered exclusively that it tends to push out a range of other treatments. This does not happen in cardiology. Counselling is often the initial treatment of choice; cheap and with a lesser degree of qualification required.

I heard recently of a single mother, abused and abandoned by her partner, a drug addict, who was not really managing to cope with bringing up small children. She would have had a few weeks of counselling in her GP’s practice and medication, followed by brief interventions by clinical psychologists but, like many others, this did not shift either her depression or her behaviour. Her anxiety was too deeply entrenched for short-term counselling to make much difference or prevent her taking her negative feelings and distress out on her children. In fact, she was one of the lucky few. She had a small, local psychotherapy unit near her and she received huge support from her weekly meetings over a long period but that unit, the Camden psychotherapy unit, will shortly lose its funding.

The trend for the full range of mental health treatments to be available only to the rich, or those who can wait a year or more, will be exacerbated if there is not parity of esteem between mental and physical illness. Noble Lords may not be aware that the treatment they or their family might expect is simply not available to more than a very few poor people. It must be emphasised again what is at risk when people's mental health is jeopardised. It is not only their happiness; it is their job, their relationships, their capacity to be effective parents, their resistance to drugs, alcohol and crime, and their home. It is of course also our economy, our well-being and our ease and peace of mind which are impaired. Explicit parity of esteem is essential to redress this cruel imbalance. These amendments serve that purpose. I urge the Minister to accept them.