Health and Social Care: State Pension

Lord Bishop of St Albans Excerpts

Thursday 21st January 2016 Lords Chamber

[Lord Prior of Brampton]

I know my noble friend feels very strongly that we should have a royal commission to look at the long-term affordability and funding of the NHS. That is not the Government’s view.

[The Lord Bishop of St Albans]

My Lords, in last week’s NHS debate, which very helpfully explored a number of areas, a number of noble Lords referred to the independent American research pointing out that among the—I think—11 most developed countries, our health service came out right at the top, except in the area of prevention. The worry that many of us have is that a lot of the money is being front-loaded on to the NHS, which is responding to immediate needs, but that the long-term need for a cross-party agreement on how we get much better at preventing illness and having health programmes is lacking. Can we yet again press the Minister to see how we can get some sort of cross-party agreement on this proactive approach?

[Lord Prior of Brampton]

The right reverend Prelate is right to remind the House of the report by the Commonwealth Fund which indicated that the National Health Service is the most efficient and overall the best healthcare system in the world. He also referred to prevention. The childhood obesity prevention strategy is due to be announced by the Government in the next couple of months. We have made huge progress on reducing smoking and in other areas of prevention, but I agree with the right reverend Prelate that prevention is a critical part of our long-term approach to healthcare.

National Health Service

Lord Bishop of St Albans Excerpts

Thursday 14th January 2016 Lords Chamber

[The Lord Bishop of St Albans]

My Lords, I am glad to congratulate the noble Baroness, Lady Watkins, on her maiden speech. Due to the pressure on time, I want to focus on one very small area, which has been alluded to by various noble Lords but which I want to develop a little. It is the pressing and vital need to reboot the concept of a social contract, which lay at the heart of the national health system as envisaged by Beveridge and which balanced rights and responsibilities, not least against the background of living in a time when people have increasingly emphasised rights and perhaps downplayed the sense of duty and responsibility.

In 2013, PricewaterhouseCoopers produced a report on the 65th anniversary of the NHS, which identified two key factors that would be essential for the future of the NHS. One of them was the extent to which people took personal responsibility for their own health and care, and that of their families. Then last year, when the independent research published by the Commonwealth Foundation revealed the UK’s health system to be at the top of the league among nations in the developed world, the one area where we did not score highly was in the prevention of illness. That report highlighted the particular problem of large numbers of people in this country with unhealthy lifestyles.

It is deeply concerning that so many illnesses are caused by addictions to alcohol and smoking, while we have the highest rate of child and adult obesity in Europe. Estimates of their cost vary but just those three areas could well be costing as much as £17 billion per annum. To address these issues requires a deep cultural change across our nation, along with a renewed emphasis on personal responsibility for our health and for exercise, for people of all ages. But of course these sorts of changes are some of the hardest to make. The need for a new social contract between citizens and the NHS is urgent, with a much greater emphasis on what we need to do in response to what the NHS provides. Indeed, this message needs to be reinforced every time anyone comes in contact with the NHS.

While laws and taxation have a contributory factor, we need to create a climate which celebrates health and people taking responsibility for it, for them and their families. There is a great deal of evidence that one of the most powerful factors in bringing about such behavioural change is the influence of peer groups. We need to work consistently with health campaigns, sports and leisure clubs, statutory and voluntary youth and children’s groups, schools, colleges, churches and everybody from the Mothers’ Union to the WI and the University of the Third Age to think how we can celebrate the need for personal responsibility. It needs to be undertaken over the long term; we are talking in terms of decades. If we are to see significant change then the evidence of the campaign to reduce smoking, which has halved since the 1970s, shows that it can be done but will take time and consistency.

Health: Parity of Esteem

Lord Bishop of St Albans Excerpts

Tuesday 20th October 2015 Lords Chamber

[Lord Prior of Brampton]

NHS England is committed to ensuring that every CCG in the land increases its spending on mental health. The general allocation to CCGs was 3.7%, and the CCGs’ commitment to spending 4.6% of their allocation on mental health will hold NHS England to account for achieving that.

[The Lord Bishop of St Albans]

My Lords, the NSPCC report on achieving emotional well-being among young people in care found that 45% of them experience mental health problems, many of which continue to remain undiagnosed. It recommends that those young people should have not only an automatic physical health assessment but an automatic mental health assessment. Will Her Majesty’s Government consider introducing legislation to give that right to all young people as they enter care?

[Lord Prior of Brampton]

I am not sure that legislation is necessarily the right way forward, but perhaps we can pick up that issue with NHS England to ensure that it is written into the NHS mandate for next year. It is certainly something I will explore with them. It is worth noting that we are spending £94 million a year on IAPT for children, and we have increased spending on tackling eating disorders in young people by £150 million over the course of this Parliament. We are beginning to rectify what has historically been an area of huge underfunding of mental health for young people.

Health: Children

Lord Bishop of St Albans Excerpts

Thursday 10th September 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, I do not have the numbers for paediatricians—whether or not there is a shortage. Certainly, there are shortages in some specialties, particularly in A&E and other emergency specialties. I cannot give the noble Baroness a definitive answer on the shortage of paediatricians but perhaps she will allow me to go back, look at the figures and write to her.

[The Lord Bishop of St Albans]

My Lords, one of the most significant aspects of child health is to do with access to health services, which is a particular problem in rural areas. The phenomenon of distance decay, the further away you are from where the service is provided, is well documented. Will the Minister tell us what Her Majesty’s Government are doing to increase access to health services for those 900,000 rural households living in income poverty?

[Lord Prior of Brampton]

My Lords, access to health services is not just a rural issue; it relates also to deprivation, be it urban or rural. I would point out to the House the increase in the number of health visitors, which has gone up from 8,000 to nearly 12,000 over the past five years, and also to the Family Nurse Partnership scheme, which now has 16,000 places on it for younger and teenage mothers. So the Government are doing a lot to improve access. I guess they could always do more.

Mental Health: Young People

Lord Bishop of St Albans Excerpts

Tuesday 30th June 2015 Lords Chamber

[The Lord Bishop of St Albans]

My Lords, I, too, am grateful to the noble Baroness, Lady Tyler, for introducing this debate, for the excellent work of the task group and for the commitment that Her Majesty’s Government have already made to this area.

I also pay tribute to the many excellent charities that are working in this area. Just round the corner from where I live in St Albans is a small charity. I do not suppose that any of your Lordships will have heard of it. It is called Youth Talk and it was set up some years ago, in 1997, by a local GP after she realised that there was a need for a safe place where young people could come for counselling and support. In the intervening years, more than 2,000 young people have used the service. Every year around 190 young people are seen and up to 50 sessions are offered each week. The service is free at the point of access to all 14 to 25 year-olds. It is one of the many unsung charities in our nation that are offering support in this extremely important area. Alongside the crucial statutory work, we need to think about encouraging the voluntary sector.

However, there is still a great deal to be done. As the former Minister Norman Lamb admitted about a year ago, for children and mental health services the prevalence data were out of date and the commissioning services were fragmented. It is good that some of these deficiencies are now being addressed. Therefore, I am supportive of the proposal in the Future in Mind report that good research in the form of a prevalence survey should be conducted by the Department of Health every five years. That would give us a wide range of data, including factors such as ethnicity and socioeconomic background, with a special emphasis on vulnerable groups.

I want to comment on two other areas. First, I strongly support the recommendation that,

“designated professionals”,

should,

“liaise with agencies and ensure that services are targeted and delivered in an integrated way for children and young people from vulnerable backgrounds”.

We are all aware of the problem of statutory and voluntary agencies working in silos, resulting in young people falling through the net. The troubled families programme has shown us the value of having a champion —a co-ordinator whose role is to focus on getting change and who can draw together all the different parties to ensure that the help can be delivered effectively and consistently. Without such “designated professionals” who are given the appropriate power and resources, it is unlikely that we are going to solve the problems that have dogged this area for such a long time.

I also want to commend to your Lordships’ House a campaign launched last Friday by the Children’s Society called Seriously Awkward. The campaign is based on empirical research of more than 1,000 teenagers of 16 and 17 years of age, and it relates directly to many of the points made in the Future in Mind report. However, it argues cogently that there are a number of areas that need urgent attention. In particular, the campaign points out that the legislation relating to 16 and 17 year-olds is highly inconsistent and is causing problems regarding where they fit and who is responsible for them. We need some clarity in this area. The campaign argues that the Government should establish a right for 16 and 17 year-olds to be entitled to support from CAMHS when they need it. This support must be available as early as possible, and long before mental health needs become acute. It argues that the Department of Health should, as it is in the process of recommissioning a new prevalence study, include 16 and 17 year-olds in that study, and there seems to be some lack of clarity about that.

Tailored information should be produced by CAMHS providers about mental health symptoms and conditions for adolescents to support them in understanding their experiences. Information also needs to be available to their families, to help them both in parenting adolescents appropriately and meeting their emotional needs. In addition, services working with vulnerable adolescents should consider their mental health needs within the family context and offer appropriate support to the young person and their family, working together.

Local authorities and health and well-being boards should evaluate the levels of mental health support available to vulnerable groups of young people. The commissioning of effective mental health services needs to be underpinned by robust and reliable data on the use of mental health services, particularly by vulnerable groups.

Finally, at present, support for victims of child sexual abuse is often dependent upon children displaying symptoms of diagnosable conditions. Child victims should, as a matter of course, receive support to help them overcome the trauma of abuse. Therefore, what are the Government doing to ensure that older adolescents have access to mental health support? Will the Government ensure that 16 and 17 year-olds are included in the upcoming mental health prevalence study of children and young people’s mental health? Will the Government ensure that some of the additional funding is ring-fenced to ensure that victims of child sex abuse have access to mental health support?

Mental Health Services

Lord Bishop of St Albans Excerpts

Wednesday 25th February 2015 Lords Chamber

[The Lord Bishop of St Albans]

My Lords, the terrible reality of the effects of mental health could not have been more powerfully illustrated than by the story reported in the press last week of 18 year-old Edward Mallen. He was not one of “those unfortunates”—he had 12 A* GCSEs and was predicted to achieve three A* A-levels; he had got grade 8 piano and a place at Girton to read geography—but he rapidly descended, over quite a short time, into depression and died under a train. Not only is it an affront to think of that young life, with all its potential and opportunities, suddenly being lost with his death, but the scars will stay with all the members of his family for the rest of their lives.

Recently published ONS figures show a worrying rise in the number of suicides in the UK, particularly among men. There were 6,233 suicides of over-15 year-olds registered in 2013, 252 more than in 2012, with the male suicide rate three times that for women. In the UK, suicide is the main cause of death of young people under the age of 35—more than 1,600 every year. Hundreds more attempt suicide and thousands more self-harm.

Much more needs to be done, perhaps drawing on research such as that provided by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. In last year’s annual report, it identified various key points at which there was much greater risk. For example, the first three months after a patient’s discharge remain a time of particularly high suicide risk, especially in the first two weeks. Between 2002 and 2012 there were 3,225 suicides in the UK by mental health patients in the post-discharge period, 18% of all suicides. The report also pointed to suicide by patients receiving care under crisis resolution or home treatment teams. Such people are much more likely to commit suicide than those in in-patient care. It also pointed to living alone as a common antecedent of suicide by patients receiving care under crisis resolution and home treatment teams.

I welcome the Government’s initiatives in the area of suicide prevention. Indeed, I applaud the Government’s ambition to achieve zero suicides through the NHS adopting the approach pioneered by the Henry Ford Medical Group in Detroit. The dramatic improvements in Detroit will give hope that those who feel such desperation and so little hope in our society can also be reached. They point to the need for rapid and thorough expert assessment of patients who are having suicidal thoughts; for improvement in the care of those who present with self-harm injuries at A&E units; for better education for the families of people deemed to be at risk; and for improvement of data collection on patients to get a better understanding of how and where patients are most at risk of suicide and then to target resources at them.

The charity PAPYRUS has highlighted the need to ensure that children, young people and vulnerable adults receive due attention under this new strategy. It is imperative that the provision of resources is sustainable and adequate to facilitate a wider understanding of people with mental health problems as well as to enable the necessary preventive training and aftercare. I therefore applaud the good work that is going on, not least in organisations such as the Samaritans and the churches. I also ask the Minister whether the Government will respond to the campaign by Mind to guarantee referrals to talking strategies, which have clear benefits for those who receive them, within 28 days.

NHS: Accident and Emergency Services

Lord Bishop of St Albans Excerpts

Thursday 15th January 2015 Lords Chamber

Asked by

[The Lord Bishop of St Albans]

To ask Her Majesty’s Government what is their assessment of the pressures facing accident and emergency services.

[The Lord Bishop of St Albans]

My Lords, I come to this debate not as a doctor with specialist medical knowledge nor with any special insights into the complex processes which hospital managers have to manage. I approach it as someone from an institution, the church, which has been concerned for healing, in its broadest sense, from its very foundation and I live opposite what is left of the great medieval monastery of St Albans, which for centuries was a centre of healing, with its infirmary and herbarium. In my present role, I have regular contact with the hospitals across Hertfordshire, Bedfordshire, Luton and Barnet, which make up the diocese of St Albans.

I also come as someone who has received the benefits of A&E departments in my own family. Not many years ago, my eldest nephew was diagnosed with a brain tumour and had to have serious surgery on several occasions. Sadly, he has since died from the tumour. About five years ago, he and all the extended family were staying with me for Christmas and, in the early hours of Boxing Day, he had a fit. I remember vividly the intense panic as we were all roused out of sleep to find what was going on; as we waited anxiously for the ambulance, willing it to come because we all felt so helpless; as he was rushed into Watford General Hospital A&E department. What a relief it was, in that terrible time, to feel there were people around who knew what they were doing. I am well aware from talking to doctors and nurses and visiting hospitals that the widespread coverage in the media about A&E departments has not only been frustrating for many of those front-line people but profoundly demoralising. I pay tribute to all who work in such departments and thank them for their tireless service, not least those in Watford General Hospital.

The House will be aware that pressures on A&E services have been mounting over a number of years. While the NHS always faces pressures in the winter, these have been compounded by our ageing population. We now have 350,000 more over-75s than four years ago. This rise has occurred simultaneously with a significant increase in A&E attendances and a greater level of sickness among those who arrive, leading to an increase in emergency admissions of nearly 6% on last year. In my own diocese, the A&E departments are facing these challenges with varying degrees of success. For the week of 5 January, Watford General Hospital fell below the Government’s target of 95% of patients seen in four hours, while Luton and Dunstable University Hospital exceeded this target, in line with its track record as one of the top 10 trusts in the country.

What is causing this? Attendances are up, but the problems go much deeper. Reports have emerged of people in some places having difficulty getting appointments with their GPs. There have been discussions about changes in social care leaving some elderly and frail people without the necessary support. There are staff shortages and recruitment difficulties in A&E units. Many in your Lordships’ House will be aware of A&E’s three main areas of activity: triage, treatment and referral. Problems tend to arise in bottlenecks at the triage and referral stages. Effective triage is compromised by the presence of patients whose needs do not fit the current services offered in A&E departments. Until quite recently, these individuals were often referred to as “inappropriate attenders”, but current research suggests that it is not the patients who are inappropriate, but the services that emergency departments provide. Estimates vary that between 15% and 40% of patients require services other than those offered by an emergency department and it is the presence of these patients that creates part of the bottleneck at the triage stage.

At the other end, efficient referral after treatment is compromised by problems in bed allocation in acute medical and surgical wards as well as by accessing appropriate services. In many cases, A&E doctors admit patients for further diagnostic tests or when the additional expertise of medical or surgical staff is required. Around 20% of referrals from A&E to acute wards involve patients whose conditions could be treated appropriately by their GPs or in the community. Up to 40% of patients referred to acute wards are discharged within a few hours of admission. The Department of Health says that the effective management of the flow of patients through the health system is at the heart of reducing unnecessary emergency admissions and managing those patients who are admitted. The problem is how to identify how this can best be done.

Much of the debate in the other place has, not surprisingly, been highly politicised because we are approaching an election. I hope that, in this debate, this House can stand back and take a more dispassionate view, drawing especially on the huge knowledge and experience of some noble Lords who have intimate, personal working experience in the National Health Service. I hope that we can set this debate in a slightly wider and longer term context. Certainly, it needs to be set against the background that A&E services across Europe are facing similar challenges.

Until recently, some emphasis has been placed on attempts to demagnetise emergency departments, even though it has long been established that this tactic meets with little success. Both self-referrals and referrals from GPs willing to short cut protocols have resulted in increased numbers of patients presenting for treatment. Some 20% of A&E patients decide to attend a day in advance, the majority do not consider going first to their GPs, and 80% fail to make use of advice services such as NHS Direct. While there has been a change in people’s expectations and preparedness to wait for an appointment with their GP, we must not overstate the extent to which A&E services are being clogged up by misuse. The vast majority of A&E users are not inappropriate attenders; that is to say, they should be within the health service.

Recently, some pilot projects have begun to change the range of services available in A&E departments. For example, some GPs co-locate in emergency departments as primary care physicians while others locate out-of-hours GP services adjacent to A&E departments. Other GP practices have supplemented NHS Direct with their own telephone consultation services, enabling patients to speak with their own doctors. There is growing evidence over the past decade that these approaches relieve pressure on A&E staff and enable efficient triaging at the front door. Similarly, pilot projects that locate acute medical and surgical staff in or approximate to A&E departments at peak times have enabled improved patient flow as additional diagnostic expertise has resulted in inappropriate admissions to acute wards being minimised. Co-location of acute assessment units has also enabled patients to be monitored and assessed without them either remaining in A&E or by being admitted to acute wards. These approaches require strong leadership, close co-operation among health professionals, focus on patient care and strategic implementation. What more can be done to enable every hospital to have its own 24-hour GP practice?

Ultimately, resolving the current and on-going A&E crisis involves a systematic change to the ways in which health and social care are organised. Access to good social and community care can relieve pressure on GPs, enabling them to play a greater, proactive role in emergency medicine. Allied with a willingness to break down barriers within hospitals between emergency departments and acute wards, strain on A&E staff can be alleviated and patient experience improved. I hope that this debate will play a small part in exploring the complex reasons for the current problems and help us in addressing the challenges facing A&E departments today.

Abortion (Sex-Selection) Bill

Lord Bishop of St Albans Excerpts

Tuesday 16th December 2014 Lords Chamber

[Earl Howe]

My Lords, our latest analysis of data by country of birth and ethnicity, which we have done for a second year running, found no evidence of sex selection taking place in the UK. Without exception, the wide variation in birth ratios was within the bounds expected. Any termination wilfully failing to meet the requirements of the Abortion Act will render those performing such procedures liable to prosecution under other legislation.

[The Lord Bishop of St Albans]

My Lords, given that many are concerned that we may not be protecting the most vulnerable in our society in this area, we need to understand the full extent of sex-selection abortion in this country, if indeed it is taking place. We need to collect and collate data. In the light of that, will the Minister tell the House what Her Majesty’s Government are doing to require the registration of the gender of foetuses using forms such as HSA4 or something similar so that we can actually have the evidence?

[Earl Howe]

My Lords, we are not moving in that direction partly because it is frequently not possible to determine the sex of the foetus after an abortion.

Defibrillators

Lord Bishop of St Albans Excerpts

Tuesday 24th June 2014 Grand Committee

[The Lord Bishop of St Albans]

My Lords, I am grateful to the noble Lord, Lord Storey, for raising this important issue and for keeping it to the forefront. When I was training to be ordained, I became used to some people going off for a little doze while I was preaching. What I did not know was that, during my very first sermon, somebody—a very nice lady—would have a heart attack. Fortunately, she did not die and I got to know her and her family very well during her convalescence. I saw something of the impact of such events on families; indeed, my sympathy goes out to those who know something of this in their own family.

Each year in the UK, some 60,000 people suffer a sudden cardiac arrest. Ambulance services are able to attend on average only 25,000 of those and the corresponding survival rate is depressingly low. Sudden cardiac arrest is therefore a key issue for us.

Time is of the essence in such instances. Survival is often dependent on quick access being gained to medical assistance in the form of CPR, defibrillation and then excellent follow-up care. I am told that, for every minute that elapses following a cardiac arrest, the victim’s chances of survival decrease by 23%. If CPR alone is available, the survival rate remains alarmingly low—at around 5%—but if defibrillation is conducted within five minutes of the arrest, the survival rate soars to some 50%. Given the stretched resources of our ambulance services and the large and often complex geographical areas that they serve, it is not always easy for professional medical assistance to be with the victim in that very short timeframe. Even the current eight-minute general response target is reached in only two-thirds of incidents. It is obvious, therefore, that for assistance to reach the victim before time runs out, we need some more help to be available locally.

The technology of defibrillation, as many of your Lordships will know far better than me—I am not a medic—has advanced in spectacular ways in recent years. The development of automated external defibrillators—AEDs—represents a huge step in the right direction. AEDs allow ordinary people like me to administer defibrillation to victims of SCAs. They are fully automated and include audio and sometimes visual instructions so that defibrillation can be carried out safely and effectively.

In recent years, thanks to the hard work of charities such as the British Heart Foundation and the Community HeartBeat Trust, many AED schemes have been initiated, which have served communities to good effect. For example, the villages of Wooburn Green and Bourne End in Buckinghamshire recently set up their own AEDs to provide the communities with the ability to treat those who suffer from SCAs in the area. In my own diocese, Buntingford Cougars Youth Football Club, which provides football training in East Hertfordshire for over 200 people, recently acquired a defibrillator for its ground thanks to money given to it by the local council. Thanks to the British Heart Foundation and the Football Association, 11 Hertfordshire football clubs recently acquired their own AED units. These things are happening; it is just a question of whether we can encourage them to happen even more often. These examples show just how much awareness has increased and how the chance of survival for those who suffer SCAs has likewise increased. The tragic case of Oliver King and the almost miraculous incident involving the former Premier League footballer Fabrice Muamba just go to show how increased awareness of cardiac arrests and the need to administer defibrillation is making a difference.

That awareness, as has been pointed out, has extended far beyond sports clubs and into schools, which are providing both defibrillators and the training that has been referred to. I will give two other examples from my diocese that I know of: Bishop’s Stortford College and the Robert Bloomfield Academy in Shefford both have AED units and are able to administer defibrillation if required. Those local examples show that things are moving. Why are we not thinking about what we can do in our churches and church halls? I want to think more about that; indeed, this debate has made me think more about it. On a typical Sunday in my diocese, we have about 30,000 people in our churches and, over a week, it is probably double that number. With the church halls, many of which have lots of events, we are certainly talking in excess of 100,000 people. These sorts of debates make a number of us ask hard questions about what we can do ourselves rather than just looking to government to do things. Sometimes we just need local communities to get on with it.

I commend the work of community first responders—volunteers trained to administer basic medical assistance, including defibrillation. They carry AEDs with them and are often able to treat the victim before the emergency services have arrived. In the east of England alone there are over 2,000 community first responders, who are able to reach those who have suffered SCAs. They are, however, only able to reach about 20% of them, which is where the work of groups such as the Community HeartBeat Trust comes in. They help to fund the installation of community AED units and provide education and training so that people are able to spot the signs of an SCA and are able to use the AED units effectively. For example, the Community HeartBeat Trust has worked with the authorities in Central Bedfordshire—part of my area of responsibility—to develop plans to install units in a number of towns and villages.

For all of this work to have maximum effect, it is essential that there are good levels of communication between the emergency services, the community first responders and AED volunteers. In many cases, the emergency services alert the community first responders in the event of an SCA, who are able to respond and treat the victim if possible. That is a great example of bringing help to patients promptly, which maximises their chances of survival, rather than simply relying on bringing them to hospital. The Community HeartBeat Trust also works in collaboration with ambulance services to ensure that all parties are aware of where AEDs are located and that those AEDs are properly maintained and ready for use.

I am convinced that the growing use of AEDs should be seen as a great and positive development in tackling the relatively poor survival rate of SCAs. However, AEDs certainly should not be a replacement for the emergency services, nor are they an alternative to improving access for all to emergency medicine. They are not suitable for all types of SCA, so it is critical that calling 999 is still the first action taken upon witnessing an SCA or coming across a victim who has recently suffered one. None the less, as part of our integrated emergency care system, in the hands of trained volunteers, community-based AEDs have the potential to save many thousands of lives each year and their deployment in schools and sports clubs as well as in public places—and, yes, I hope in churches and church halls as well—ought to be encouraged and supported. I hope that we can move that forward.

NHS: Mental Health Funding

Lord Bishop of St Albans Excerpts

Wednesday 2nd April 2014 Lords Chamber

[Earl Howe]

I agree with the point made by the noble Baroness. Prevention is much better than having to cure. I pay tribute to those organisations that champion the cause of those with autism. It is a tribute to the previous Government that they published the Autism Act, part of which involves collecting evidence at local level about the population affected by autism and, in that way, focusing minds at local level—principally the health and well-being boards—to direct services appropriately.

[The Lord Bishop of St Albans]

Given the significant disparity in mental health diagnosis, treatment and outcomes between minority ethnic groups and the general population, what steps are being taken not only to uphold parity of esteem between mental and physical health but to reflect that in the provision of accessible and effective mental health services for all people?

[Earl Howe]

The right reverend Prelate raises an important dimension of this whole issue. We have been looking at ways to overcome inequalities in access to services, which includes better access for black and minority ethnic communities to mental health services. For example, we know that people from BME communities have been less likely to use psychological therapies. To tackle that, the department is working with the Race Equality Foundation and other stakeholders to understand why that is so and to understand inequalities around access to other mental health services and what can be done to improve that. NHS England is also working with BME community leaders to encourage more people to use psychological therapies.