Cost of Living: Public Well-being

Lord Layard Excerpts

Thursday 20th October 2022 Lords Chamber

[Lord Layard (Lab)]

My Lords, we all know the problem facing our country: as a nation, we have become poorer. Our import prices have risen more than our export prices and, on that account, we are 5% poorer than we were a year or so ago. That is a lot of money—over £100 billion a year—and it is something we cannot escape.

This is the issue that the Chancellor is facing: who should bear the cost of the loss in our national income? It could be working people, the owners of capital or the public services—those are the only three parties that could be cut to bear this cost. Or it could be some combination. This is an agonising dilemma; I think the Chancellor called it “eye-watering”. So how should the Chancellor decide between these three parties and the sub-groups within them? What criterion should he use to make the decisions? The answer of course lies in the brilliant way in which my noble friend formulated the issue for this debate: it should depend on the way in which each of the alternative options would affect the well-being of the population. This is the new approach—it is totally feasible, and we should adopt it.

For example, we know a lot about what affects well-being. The first thing we know is that a loss of real income matters more to the poor than to the rich. To be specific, the loss of £1 hurts a person on low income 10 times more than someone who is 10 times richer. So, as others have said, the top priority for the Chancellor must be, as other speakers have said, to fully protect the real incomes of those on lower incomes.

When it comes to richer citizens, there are real issues about what is most important to them at the margin: is it their own spending power, in real terms, or is it also the services on which they depend? Here, too, well-being science provides important insights. In explaining the spread of well-being, real income is not the most important thing: health always comes top, especially mental health, as the noble Baroness said. Then comes stable family life, happy work and workplaces and safe communities—and only then comes income. When people are asked—in a survey commissioned by Sainsbury’s, for example—about their main worries in daily life, it may surprise Members of this House and the political class that the order is the same: income and debt come about sixth in the list. So public services are crucial to all of the other things that affect well-being, as well as income.

We desperately need a fully functioning NHS, proper social care and a functioning court system—and we do not have any of them. We also need safety on our streets. These services are already under massive pressure, which will get worse due to unanticipated inflation. The last thing they need is further cuts of the kind that are being discussed these days. So, if well-being is the goal, services also have a case for some inflation protection—why are we going to protect only households and not services? At the very least, they should not be subjected to further cuts. To balance the books, we have to look elsewhere: proper taxation of excess profits in the energy sector, for example, and a sensible approach, from next April, to how far we protect the real incomes of families with above-average incomes.

Let me give some illustrative figures that I think are relative to the issue of what is in the interest of people with above-average income. If a person suffers from clinical depression or an anxiety disorder such as PTSD, their well-being—measured in terms of life satisfaction—falls by 0.7 points out of 10. Similar is true of addiction, personality disorder and eating disorders, which wreak havoc on so many families and communities—0.7 points out of 10. By contrast, if a person’s real income is halved, their well-being falls by 0.5 points or less.

Let us apply these apply these numbers to the Chancellor’s dilemma. He could be spending money on psychological treatments. Good ones exist for most mental health conditions but are simply not available to millions of the people who need them. An extra £1 billion a year here would make an incredible difference. By contrast, the Government presently spend £120 billion annually on protecting people’s real incomes. There is a huge difference there.

We could just ask: suppose we took £1 billion away from the protection offered to people with above-average incomes and gave it to mental health? What would happen to well-being? I can tell noble Lords from the evidence that the impact on well-being of giving £1 billion to mental health would be 50 times higher than giving the money to people with above-average incomes. I think that calculations for other public services would confirm the case for at least protecting them, and probably expanding them.

We constantly hear, as if it were shocking, that public expenditure is now at its highest level relative to national income than at any time since the 1940s. Of course, that is just as it should be. It is exactly right. As people get richer, the impact of extra income on their well-being declines. That is what economists for several centuries have called the diminishing marginal utility of income. But if you think about the impact of health on well-being, that remains exactly the same, however rich you are. So do the impacts of ignorance, loneliness, addiction and crime. We should be giving proper attention to the public services which can help us with the things of enduring importance to human beings; in particular, the social infrastructure of their lives.

If we want to maintain national well-being in these difficult times, the top priorities must be to protect the real incomes of the poor—I hope the Minister can say something about that—and to protect the public services on which we all depend.

Health and Care Bill

Lord Layard Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Lord Layard (Lab)]

My Lords, Amendment 101B, in my name and those of the noble Baroness, Lady Watkins, and the noble Lord, Lord Alderdice, is a fundamental amendment to remedy the shocking imbalance between the provision of mental and physical healthcare. As was said in the debate last week, people with mental disorders who receive treatment are a minority—35% of children and 40% of adults—while for people with physical illnesses, the vast majority get treated. This is not parity of esteem; in fact, I think it is one of the greatest cases of discrimination in our public life. There is only one way to remedy it, which is that the funding of mental healthcare has to rise faster than the funding of physical healthcare. In other words, the fraction of NHS funding devoted to mental healthcare has to rise—it is a matter of simple logic. This is such a fundamental point of principle that it should be put into law.

The increase does not of course have to go on for ever, but only until the inequality has been eliminated and mental health is treated like physical health. In the words of the amendment, the rise should continue until

“people coming forward with mental health problems are as likely to be offered treatment as people with physical health problems”,

and, of course, to receive it within a period of time appropriate to their problem. Only then will we have achieved parity of esteem.

The amendment is a statement of principle. As we know, there are always problems of definition and interpretation with statements of principle, but such statements are common in our statute law. This is a sector, in financial terms, as big as the police service, and it is right that there should be legal principles governing it. If we want to secure justice for the sector, it needs a statement of principle. This is a stronger statement than any of those discussed last week, but if this is what we believe, it is what we should say.

The main argument for the amendment, as I have said, is one based on simple equity, but there is also a strong economic argument. Mental illness is mainly a disease of working age, while physical illness is mainly a disease of retirement. Half of all working-age disability and absenteeism is due to mental illness, so when we successfully treat mental illness, the savings to the economy and to the Exchequer are massive, especially when compared with the economic savings from the majority of physical healthcare. These economic savings were a key argument that led to the establishment of IAPT, Improving Access to Psychological Therapies, from 2008 onwards, and they have been verified in what has happened since in that service.

There is also another very important source of savings: savings to NHS physical healthcare. Psychological therapy has been shown to reduce the cost of physical healthcare for people with comorbid physical conditions. This can be seen in a major nationwide controlled trial done recently, which provided IAPT treatments to people with long-term physical conditions such as diabetes, CVD and COPD. This trial found that, within a year, the savings on physical healthcare covered the total cost of the psychological therapy—so the mental health service is saving money for the physical healthcare service. As a result, this approach is now being rolled out nationally.

So mental health is a classic case of spend to save, and extra spending is desperately needed. Some of it would fill the massive gaps in existing services, including for severe mental illness, and some of it would provide services to key groups of people who are barely helped at present, many of whom were referred to earlier in this debate.

First come the tragic children who fall below the CAMHS threshold, who are sometimes assessed and sent back home as not sick enough, but who desperately need help. For these young people, the Government are developing mental health support teams in schools, but the rollout is incredibly slow and the services also need to include a much higher level of expertise.

Then there are millions of people whose lives are wrecked by addiction to drugs, alcohol and gambling and who need psychological therapy. There are the victims and perpetrators of domestic violence, who have already been mentioned, and other forms of violence. So many of our social problems have a strong mental health component. There are good, evidence-based psychological treatments which NICE recommends for these problems, but they are not provided. They should be provided. Extra spending on mental health could massively improve our society.

There is one further point in the amendment. If we spend the money, we need to know what it is achieving. In IAPT we know the progress of 100% of those treated, but in most parts of adult and child mental health services we currently have very little quantitative data on what is being achieved. That has to change, so universal routine outcome measurement should be a reasonable quid pro quo for extra funding, but the extra funding is crucial. It is not enough to talk about parity of esteem. We must have a clear statement of how to recognise it and the funding principles to achieve it.

[Baroness Watkins of Tavistock (CB)]

My Lords, I rise to speak to this group of amendments with an emphasis on Amendment 101B, in the name of the noble Lord, Lord Layard, whom it is a pleasure to follow.

Last night, I went to the ballet and saw “Raymonda”, which has been placed in the context of the Crimea. It reminded me that Florence Nightingale took a hammer to a store-cupboard to get food and blankets for some of her patients because nobody knew what was inside it. She went on to be a leader in sound data for health- care, recognising that without data we could not plan for the future. This amendment emphasises measuring the outcomes of mental health nursing and other mental health interventions in order to ensure that we learn from practice and develop best practice cost-effectively. That is why I have put my name to Amendment 101B.

We need to look at similar patterns for care to those for physical illness. For example, the onset of paranoia and delusions which threaten the safety of an individual or those close to them could perhaps be equated with a suspected cancer where you wait for two weeks for an initial diagnosis. How many people are sectioned under the Mental Health Act for assessment because they have not managed to get an out-patient appointment for assessment earlier? I believe that is an example of discrimination against people with severe mental health problems. If we could get parity of access for assessment, it would be an extremely good beginning. I recognise that there are other physical and mental health problems that are less urgent, but I use that as a comparison.

Yesterday at a meeting concerning mental health reform after the pandemic, the Minister for Care and Mental Health Gillian Keegan and the chief executive of Mind were panellists. At that meeting, it was noted that investment in NHS mental health services currently increases year on year, largely due, I think, to action under the leadership of the noble Lord, Lord Stevens of Birmingham. It was £11 billion in 2015-16 and is £14.3 billion today and it will continue to increase, including an additional £2.3 billion by 2023-24. It was said yesterday that the Government will ensure ICBs will increase spending on mental health in their area in line with growth in their overall funding allocations to meet the mental health investment standard. To address backlogs, the Government have published their mental health recovery action plan backed by an additional £5 million to ensure that the right support is in place. This illustrates that the Government are committed to the improvement of mental health services. The amendment would place a duty to monitor this investment and evaluate its effectiveness. I hope that the Minister feels able to support the principle behind the amendment and will meet those of us interested in this area to try to find a summary solution to the issues we are raising on parity not only for mental health care but for the care sector that has been outlined so comprehensively by my noble friend Lady Hollins.

All the points that were made by the noble Lord, Lord Black of Brentwood, concerning osteoporosis could be made for drug-induced psychosis, schizophrenia and other severe mental illness problems. I hope that this Committee will be able to influence an amendment to the Bill that will ensure that the monitoring outlined in the amendment introduced by the noble Lord, Lord Layard, will be taken forward.

Coronavirus

Lord Layard Excerpts

Thursday 12th March 2020 Lords Chamber

[Lord Bethell]

The supply of medicines is of concern. We have built substantial stockpiles of all medicines that we feel we need. We are working through what the implications of President Trump’s declaration might be. My understanding is that we are presently very confident about the secure supply of medicines.

[Lord Layard (Lab)]

My Lords, if we look abroad, especially to Japan and China, it is clearly not as inevitable as the Government assume that this disease will become widely spread through the population. Extraordinarily, in Hubei province, the epicentre of the disease, the proportion of the population who caught it was 0.1%. So how can we be hearing our experts talking about up to 80% of our population being affected? This cannot be right; it is based entirely on the assumption that our approach will be very passive. Can the Minister assure me that we will move to a really stringent regime next week?

[Lord Bethell]

The noble Lord asks a question that is on the minds of a lot of people who have been reading into the subject. The concern of the CMO is that if you bring intense social behaviour restrictions to bear on a population, you can temporarily suppress the spread of the virus. If you ask the entire population to stay at home, and close down every business, public space and event, you can suppress circulation. However, the moment you lift those restrictions, the virus spreads with a vengeance. It is often the most vulnerable who are then hit with a second peak, which can take out the provisions needed to support them. That is the CMO’s primary concern. The Government’s objective is to manage the situation so that the virus spreads in as limited a way as possible, and is spread out over time to allow medical and social care resources to be given to those who need support.

Queen’s Speech

Lord Layard Excerpts

Tuesday 22nd October 2019 Lords Chamber

[Lord Layard (Lab)]

My Lords, the first question one should ask about any Queen’s Speech is: what is the overall objective of government policy? Is it the nation’s wealth? Is it the well-being of the citizens? What is it? To have coherent government, you must have an overall objective against which to measure policy. More and more people worldwide are demanding that the objective should be human experience—the well-being of the people—and I agree with that.

How does the Queen’s Speech stack up against the objective of well-being? Not well, I fear. To see this, let me compare the Speech with a recent report from the All-Party Parliamentary Group on Wellbeing Economics. The report addressed the key issue of what priorities for public spending would be if it were targeted at the well-being of the people—at the things that people really worry about. It concluded that the top four priorities were: better mental health services, which many noble Lords have said; secondly, child well-being and schools; thirdly, further education and apprenticeships—the transition to work; and, fourthly, social care. Of those four objectives, none of the first three appears in the Queen’s Speech, although they are things that parents—and all adults—are crying out for positive action on. Instead, the Speech is full of punishments of all kinds and the new strategy for the nation’s physical infrastructure. Those are the main priorities in the domestic part of the Speech.

What about the social infrastructure of our country? Over the past 10 years, we have closed hundreds of children’s centres, youth clubs and community centres. We have produced a crisis in child mental health. What is the sense of spending what new money we have on, for example, building high-speed rail, before we have rectified the desperate shortcomings of our social infrastructure? Many argue that the top priority must be physical infrastructure because that is what the market is willing to fund, because it gives a financial return, but so does social infrastructure. I shall give some examples from the field of mental health.

The NHS programme for improving access to psychological therapies has been found, within two years, to save more in reduced welfare benefits and reduced physical healthcare expenditure than the total amount spent on the programme. The net cost of the programme is zero. Similarly, if you are worried about adolescent knife crime, a proven method is to train the parents of badly behaved youngsters when the youngsters are aged five to seven. This training has been shown to reduce anti-social behaviour 10 years later by well over half, and it costs very little. Remarkably, we used to have such training. We had 4,000 people trained as parent trainers but, under the coalition Government, those services were cut as part of the general cut to social infrastructure. Those people are still there and are ready for re-employment—if only we put our next available money into that kind of provision.

As has been said, we have to upgrade and accelerate the general rollout of mental health services in schools, and the teaching of life skills in the school curriculum. These are key to producing a happier generation of children, and a generation that causes less trouble to adults. What is so depressing about the Speech is its almost totally punitive approach to any kind of behavioural problem. The word “rehabilitation” appears once and “prevention” never appears, yet there are good psychological treatments and preventive programmes for all kinds of behavioural problems, such as domestic violence, which is rising in priority, and family conflict. Only small sums of money are needed to make major inroads into these problems. How much more important to do this than to build yet another bit of high-cost physical infrastructure.

On further education, I had high hopes of the Government because they said it would be a priority. Very little money has been provided so far—only one year of it—and no programme has been announced for how to deliver the universal rights to level 3, which the Augar report recommends, which in turn requires that we remove the cap on further education, just as we have removed the cap on university and higher education. All these deficiencies come from there being no clear overall objective of government policy to influence priorities. The time has come for every political party to commit to the objective of well-being and to support that with a social infrastructure strategy. I very much hope that the next Queen’s Speech will do just that.

Mental Health of Children and Young Adults

Lord Layard Excerpts

Thursday 16th May 2019 Lords Chamber

[Lord Layard (Lab)]

My Lords, in her excellent speech my noble friend Lady Royall described the dismal state of access to treatment for young people with mental health problems—a point repeated by almost every speaker. The question is how to deal with it. I think that the way forward is quite clear, because the situation for children now is almost exactly the same as it was for adults in 2008. However, since then, the situation for adults has been improved radically through the programme for improving access to psychological therapy, otherwise known as IAPT. This includes a large programme for training therapists, plus new services rolled out across the country to deal with all but the most serious cases, who continue to use regular mental health services.

What we need to do for children now is exactly what has already been done for adults, and that is the approach that the Government agreed to in the Green Paper. That was an excellent document. It proposed creating a nationwide system of mental health support teams to do for children what IAPT has been doing for adults. The teams will take all those cases that fall below the very high CAMHS threshold, and typically they will do that in the friendly setting of a school. Therefore, this is a moment of great hope and I congratulate all those in the Department of Health and Social Care and in NHS England who have brought us to this point. However, I also want to raise three key issues in respect of which I think the programme could be significantly strengthened.

The first is training. At present, the training is mainly for handling only mild to moderate problems. However, unless the service can also handle moderate to severe cases, it will end up passing many children who start off in it upwards to CAMHS and the blockage in CAMHS will continue, just as happens now. Therefore, in these new support services we need a stream of “high-intensity” therapists, as they are known, working with young people in the same way as they work with adults in IAPT.

The other issue is conduct disorder, which is not adequately covered in the training of the support teams. It is as serious a problem as anxiety and depression. We have already trained 4,000 practitioners to deliver the group training of parents of children with conduct disorder but very few of them are being used. We should be using them.

The second issue that I want to raise is the management of the service. When adult IAPT started, it was helped enormously by an expert reference group, which included leading psychological therapists, who brought their experience to bear on the design of the service and, conversely, carried back to the profession their own excitement about what was happening. However, we do not have any such group for children, and many leading figures in the profession feel excluded from the process. That is a real pity, and I hope that the Minister can assure us that such a group will be created. I hope that she can also assure us that the more ambitious training scheme that I have mentioned can be put in motion.

The third issue is scale. The Government have allocated only £250 million to the support teams over the first three years. In current money, that is half the figure that was spent on adult IAPT in its first five years. This timorous approach means that, as has been mentioned, under a third of the country will be touched by the new children’s service in the first three years. Surely we should be more ambitious than that. In fact, I would like to suggest that we should be more ambitious about mental health overall. Since 2000, mental health has been the top priority of the NHS—that is what has always been said—but the share of NHS expenditure has remained exactly the same. That will change only if the NHS has a specific, separate, ring-fenced budget for mental health. This is an issue that we should all think about. I suggest that we need a budget for mental health growing at 6% a year in real terms compared with 3% for physical health.

Finally, I would like to ask two questions about schools. First, the Prime Minister has promised to enable schools to measure the well-being of their children. That is an excellent idea that will affect schools’ ability to help children and incentivise them to take well-being much more seriously as a goal alongside academic achievement. However, we have not heard what is going to happen as a result, and what I have heard has been worrying. Can the Minister tell us what, concretely, is going to happen with the Prime Minister’s promise?

My second question concerns life skills. This Government have been the first to make life skills compulsory. That is a huge and excellent step forward, but they have not said how much time as a minimum should be devoted to life skills. In some schools, it will be rather a small amount. Can the Minister assure us that some guidance will be given on the minimum amount of time to be spent on this? I suggest that it should be at least one lesson a week.

Therefore, things are moving forward, as many speakers have said. That is wonderful, but surely they need to move a lot faster.

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

Lord Layard Excerpts

Thursday 26th April 2018 Lords Chamber

[Lord Layard (Lab)]

My Lords, I, too, congratulate the committee and, like many earlier speakers, think that something more radical is needed on funding. The fundamental problem with the present system is the complete disconnect between the Government’s funding decisions and, on the other hand, what the public want and are willing to pay for. For example, in a recent MORI poll, people were asked to pick out their preferred option for the NHS, and no less than 66% of the public picked out the following option:

“I would be willing to pay more taxes in order to maintain the … spending needed”,


in the NHS. However, the problem is that under the present system there is no mechanism by which they could implement their wish. Taxation and spending are totally separate issues in the way the system operates, and the public will get what they want only if we can find a way to bring the two together—and that is of course a hypothecated tax.

If you have a hypothecated tax and the public vote for a manifesto, they are voting simultaneously for the end and for the means. You have to bring the end and the means together into a single decision. So I am happy that our colleague, the noble Lord, Lord Macpherson, formerly of the Treasury, has asked me to say that he now favours hypothecation. The Treasury is the main obstacle to this proposal; it wants to make the spending decisions and thinks that it is best placed to do the trade-offs. But it is the Treasury that got us into the mess we are in now.

One obvious objection to hypothecation is that the health service needs certainty about its funding, while taxes are uncertain and depend on the business cycle. I discussed this issue in my evidence to the committee, and the following arrangement would work well. At the beginning of each Parliament, the Government would present a 10-year plan for the NHS, including services, workforce and expenditure. The second five years would be indicative, but the first five years would be a commitment. Associated with that commitment would be a preannounced rate for the health tax such that the forecast proceeds would equal the committed expenditure over the Parliament. If in the upshot because of the cycle there was some difference, year by year or even overall, between the proceeds of the tax and the committed expenditure, the Treasury would make up the deficit or collect the surplus.

As many people have said, we want a funding system that simultaneously covers health and the part of social care that is paid for by public funds. As some other noble Lords suggested, we would have to extend the insurance tax base to include all income at all ages. However, once this was put in place and we had converted the national insurance system into national health insurance and raised enough extra money for the health and social care system, which would be needed, to some extent we could cut other taxes which currently finance health and social care.

I will end on the issue of what scale of expenditure would be likely to emerge if we had such a system. First, over the last 40 years health expenditure has steadily risen as a share of the national income, except in the last decade, and that has been so in every advanced country, including in our own. We ought to expect that pattern to be ongoing, because it reflects people’s preferences on how they want to spend their additional income. But in addition to that we need a rapid one-off upward adjustment to get us back on track, because we are off track. That is what people say they want, as I quoted, and I will also give your Lordships another research-based reason for a one-off adjustment.

This comes from happiness research—something I practise—which shows that physical health and, even more, mental health, have very large impacts on human happiness. These impacts are also very large when compared with the effect of variations in household disposable income after tax. In spite of the huge importance of health, health spending is now rationed by the NICE regulations, which require that you have to have at least one extra—this is jargon—quality-adjusted year of life for every £30,000 spent. It will not allow you to spend the £30,000 unless you have one extra quality-adjusted year of life as a result. But from happiness research we know that, when households collectively give up £30,000 in taxes, they lose only one-thirtieth of a quality-adjusted year of life. So spending more on health gives you a benefit-cost ratio of 30, which is a pretty good argument for spending more money.

So we need a hypothecated tax, and I see no reason why the British public would want to spend less than the average percentage of GDP that is spent on health in northern Europe. That would require an extra £40 billion a year as of now. That is the direction in which we should move, and we should move as fast as possible.

Mental and Physical Health: Parity of Esteem

Lord Layard Excerpts

Thursday 10th October 2013 Lords Chamber

Moved by

[Lord Layard]

That this House takes note of the implications of parity of esteem for mental and physical health, as required by the Health and Social Care Act 2012.

[Lord Layard (Lab)]

My Lords, by an extraordinary coincidence, today is World Mental Health Day, so I wonder whether it is not due to ballot rigging that we are having this debate today. This is also the time when the Government are preparing the next mandate for the National Health Service, so the timing of this debate could not be better.

Of course, we would like to be in a situation where we did not need to debate parity of esteem, but I start from one simple fact. We have 6 million adults in England suffering from depression or crippling anxiety disorders, and of them only a quarter are in treatment. You can compare that with people with physical conditions where, in most cases, more than 90% are in treatment. The same is true of children: only a quarter of those who would be diagnosed as mentally ill are in treatment. That is not parity of esteem; it is a really deplorable situation. What is the reason? The reason is the lack of parity in the provision of care; that is the central reason.

Of course, medication is available for most people who come forward with those problems, but most of them would prefer, or would want in addition, psychological therapy. We have excellent psychological therapies with 50% recovery rates for anxiety and depression conditions, for children’s disorders and so on, and NICE has reviewed all of them and recommends that psychological therapies ought to be offered to all patients with mental health problems. However, that recommendation is largely disregarded in huge areas of the country where those therapies are not available. Let me give just one extra argument why they should be available—other than the obvious humanitarian argument that we should treat people who are ill; that is why we have a health service. In this case, there are also huge savings to be had if we treat them. Those savings in welfare benefits and extra taxes would pay for the cost of the psychological therapy. That is a complete, 100% offset. Another probable 100% offset is in the cost of additional physical care that mentally ill people demand.

So the argument for making those therapies available is overwhelming, but it is happening very slowly. As Sir Mike Rawlings, the former chairman of NICE says, this is the area in the whole of the NHS where NICE recommendations are the most flagrantly and casually disregarded. If the same thing happened with cancer or heart disease, there would be uproar. That is why what happened in this House two years ago was so important. It was the landmark moment for millions of people because the amendment that we passed in this House introduced the principle of parity between mental and physical health. The issue that we must discuss today is what that means. That was not said in the Bill. We need to discuss exactly what that means and how we would know if we got there.

I want to suggest two simple principles. First, NICE guidelines should be as faithfully implemented for mental illness as they are for physical illness. That is a very simple principle. Secondly, treatment should be provided speedily when it is needed, as it generally is in the case of mental illness. Those two basic principles should guide the way forward. How do we get from here to where we need to be? The mandate, which is now under discussion, is the key. I very much hope that the Minister can help us with some improvements in the draft of the mandate which has been circulated for comment.

Let me start with waiting times. It is shocking that there are waiting times for hospital treatments and no waiting times for psychological therapy. This is not acceptable. Depression and anxiety are pressing conditions; more pressing than some physical conditions, although obviously less pressing in most cases than cancer. With cancer we talk about two weeks. It seems clear that we should be aiming at a maximum wait for access to psychological therapy of 28 days. Many people have argued this. I very much hope that that can be included in the mandate.

Of course, that raises the question of what scale of service would be needed to achieve that objective. The main provider of psychological therapy in the NHS is Improving Access to Psychological Therapies—the programme known as IAPT, launched in 2008. It has been very energetically and faithfully supported by Ministers from all political parties, for which everyone is extremely grateful. The programme grew rapidly, but 80% of those treated still wait for more than 28 days. Some wait for more than 12 months. Waiting lists are rising as people become aware that there is some hope in their lives.

How large a service is needed to implement the NICE guidelines for all who need them? By 2011, in the third to fourth full year of the programme, the programme was seeing more than half a million people. But that of course is only 10% of the 6 million with the condition. Since 2011, the programme has stalled due mainly to poor priorities on the part of local commissioners, the dislocation of the messages coming down to them and the pressure on them from the higher levels of the NHS as it is being reorganised.

I think we can all agree that 10% is a completely unacceptable figure. The Government have already committed to 15% by 2015, but even that deals only with the tip of the iceberg. From our experience in the first three and four years of the programme, it would be feasible to reach a figure of 25% by 2020. I would urge the Government to be thinking in those terms.

The Government, rightly, will want to have people not only treated but recovering. That is the right way to be thinking and that is where the IAPT programme is so strong because we know how many people recover. Patients are monitored on a meeting-by-meeting basis and there is now a 45% recovery rate for the patients who have two or more sessions. The Government target is 50% and the right way to express a vision for 2020 would be the numbers of people who have recovered as a result of treatment.

So I hope that the Government will be giving some indication of that longer term perspective in the mandate. It is really important because we can get good people to train as therapists for the service only if they see that the number of jobs will go on expanding. We will get commissioners to commission this service at an expanding rate only if they see that they are expected to do that and block in increasing sums. Too many of these commissioners have concluded that they have done what they need to for IAPT, which is how it has stalled. It has to be restarted, so I urge the Minister to include at least some phrase in the mandate, if he can, such as “continuing expansion of access up to 2020, linked to 50% recovery rates”. Some phrase of that sort would show that the Government and the service are serious about this. We know that the good will is enormous towards IAPT on the part of the coalition Government, but can they please set this down in some concrete way that commissioners can read and see that they have to act on?

There are of course financial constraints and commissioners are always tempted to dumb down in areas which look like soft targets. Incredibly, one commissioner will not pay for any patient receiving more than two sessions unless they can be shown to have recovered. This is an outrage but there are many who will pay only up to a maximum of six sessions for any one patient, as if they would cut an operation short if it happened to need more than the standard time. This is absolutely unacceptable discrimination and it is rife throughout the commissioning system. How can we deal with it? It would be by pressure of all kinds from above and, of course, with a constant emphasis on outcomes. I place great hope on the measurement of outcomes as the ultimate source of pressure on commissioners. When we get to outcomes-based payments, which we may in a few years’ time, we must again resist the pressure to dumb down by leaving the tariff price free for the local commissioner. There has to be the national reference cost, otherwise this will again be the soft area which gets dumbed down.

I have one final comment on the IAPT programme. It is currently in the list of 10 services suitable for “any qualified provider” treatment, together with incontinency services, wheelchairs and a few other things. Is the treatment of depression and anxiety really worthy of being treated like that? A recent study from the World Health Organisation compared the disabling effect of depression with that of angina, asthma, arthritis and diabetes. I hope it is not surprising to Members of this House that depression was 50% more disabling than each of those four conditions. One wonders why those four were not included in the list, together with incontinency and wheelchair services. If there is confusion about parity of esteem at the centre, no wonder there is even more confusion at the local level.

I have concentrated on depression and anxiety disorders. There are many other mental health problems for adults, and of course for children as well, which I am sure other noble Lords will talk about. But I want to mention just one general point: research. According to the WHO, mental illness accounts for 38% of all illness when weighted by severity in this country and 23% of the total burden of disease, including premature mortality. But what percentage of health research goes on mental health? It is 5%. We need much more mental health research. We need more trials on therapies other than CBT and many more on therapies for children. For adults we do not even know about effective group treatment, which could be very economical and effective compared with individual treatment, and so on. Most trials in mental health are very short follow-ups compared with the decade-long trials for treatment of physical illness. All this should be changed and there should be some statement about it at this point, although it cannot be changed overnight.

I hope that the Minister will reassure us on the four points I have raised—the 28-day maximum wait; the commitment to continued expansion; taking psychological therapy out of the degrading position of coming under AQP, which leads to many of these terrible commissioning decisions; and more research for mental health, especially psychological therapy. We know that the political pressures coming for psychological therapy are trivial compared to the pressures on politicians from those who suffer from most physical illnesses—especially, of course, those which are helped by the pharmaceutical industry—but one third of all families include someone with a mental health problem. Many are silent because of shame, but I think that they will privately thank any politician who shows that they understand their problems.

It is an amazing fact that mental illness, as the surveys show, causes more misery in our society than physical illness does, causes much more than unemployment or poverty do and costs the Exchequer £60 billion. It is extraordinary that it still has such a low priority on the ground. I think that we still live in the materialistic shadow of William Beveridge. As noble Lords know, he identified five great giants—poverty; unemployment; undereducation; poor housing; and physical illness—but he omitted the problems of the human spirit within. This has caused us decades of unnecessary misery. It is time to name the sixth giant, the great, hidden problem in our society, and that is mental illness. If it had parity of esteem, it would have its own Cabinet Minister, like the other subjects I just mentioned. Perhaps the best test of when we eventually have parity of esteem is when we have a Cabinet Minister for mental health. I beg to move.

--- Later in debate ---

[Lord Layard]

My Lords, I thank everyone who has spoken in this substantial debate. We have had 15 excellent contributions and somehow, miraculously, they have been almost entirely complementary to each other, so in some way we have written a pretty good textbook on the subject in these three hours. As everyone has said, this issue is a massive problem, which is why we are all extremely grateful to the Minister for taking this problem seriously today, and indeed I know that he takes it seriously on all occasions.

I am grateful for what people have said and I agreed with almost everything, including most of what the noble Baroness, Lady Murphy, said, on which I, too, would like to comment. It is quite misleading to suppose that there is something called the mental health budget, which is then allocated between psychotic illness and common mental health problems. We have never argued for more expenditure on anxiety and depression at the expense of severe mental illness. What we have pointed out is the remarkable fact that a mentally ill person with a physical illness of given severity costs the NHS 50% more in physical healthcare than someone without mental illness in the same physical condition. If we can cure the mental illness or alleviate it, there is an awful lot to be saved on unnecessary physical healthcare.

Most commissioners should be able to fund the extra psychological therapy out of the savings that they can expect from their physical healthcare bills, particularly their references to the secondary sector. One could document how those are affected immediately when someone’s mental health improves. There is a huge amount of evidence on all that. On top of that, of course, taking the Government as a whole, there are the savings on benefits and lost taxes. When we can say that it certainly costs the Government—and probably costs local commissioners—nothing to expand treatment for people with depression and anxiety disorders, which are extremely serious problems, it makes no sense to say that we should be concentrating only on people with even more serious problems. Both groups must be helped.

As I said, there have been many wonderful speeches. I thought that the letter read out by the noble Baroness, Lady O’Neill, really says it all; it caught the basic point that everyone is making. I was also delighted when the noble Lord, Lord Alderdice, raised the issue of the comparative suffering from mental and physical pain. I have been trying to look into that topic and have found quite a lot of research on it. Many studies show that when people are asked how happy they are with their lives and then record the different dimensions of their health situation, it is found that mental pain reduces happiness more on average than physical illness. In a way, we have to justify our argument for parity of esteem, and I think that that is the justification: these are extremely serious conditions affecting the well-being of the people affected. Many people have made that point, and it is a central argument for parity.

I think that if in decades hence we look back on where we are today, we shall be able to see a lot of progress. I think that people will be amazed when they look at how mentally ill people were treated, even now, and they will find it quite difficult, just like we find it difficult to believe how slaves and so on were treated, to believe that we treated mentally ill people with as much blindness and cruelty as we have been up till recently.

Motion agreed.

NHS: Mental Health Services

Lord Layard Excerpts

Monday 8th October 2012 Lords Chamber

[Lord Layard]

My Lords, I, too, am grateful to the noble Lord, Lord Alderdice, for securing this debate. I declare my interest as a national adviser to the IAPT programme and chair of the group to which the noble Lord, Lord Alderdice, referred.

We are now at a critical juncture in relation to the IAPT programme. On the one hand, we have some wonderful features. We have the Government’s commitment to parity of esteem for mental health, which is very important. For the out-service we have the Government’s commitment to providing treatment in 2015 for 15% of the 6 million people suffering from depression or anxiety disorders, which is a very important commitment. As part of this, the Government have also committed to training 800 therapists a year over a three-year period.

The issue is what is happening on the ground. Up to 2011, the programme was an extraordinary success. Starting from scratch it reached, within three years, 10% of those 6 million people. That is extraordinarily good going from a standing start. This is not a service that was being modified; it was created in a vacuum, which was a really major achievement. Equally, on the training side, 3,400 therapists were trained in evidence-based therapies, using a state-of-the-art national curriculum developed by the central team and its experts. The outcomes were also good. Recovery rates approached 50%, which was the target, and the programme has been extraordinarily successful in measuring the outcomes of its patients. In fact, it has accumulated the largest body of patient-reported outcomes, physical or mental, in the whole of the NHS.

All these achievements have been brought about by the fact that there was a central leadership with good administrators and a good network of experts co-ordinated within the Department of Health and by the extraordinary contribution and self-sacrifice of the outstanding clinical director, Dr David Clark—I must mention that because we have been extraordinarily privileged to have perhaps the world’s leading clinical psychologist leading this programme. It is therefore not surprising that the world’s leading scientific journal, Nature, last week acclaimed this as a world-beating programme. People all over the world are looking to it to see if it can continue developing.

However, although the programme is only half way through its development phase, its future is already in doubt and, as I mentioned, the Government are at serious risk of not achieving their commitments for 2015. In 2011-12 there were 530 training places, not the Government’s commitment of 800, and numbers are looking even more precarious in the present year. Services for patients are not expanding, as would be required to get from 10% to 15%, but are being cut in some localities and are standing still in others. At the same time, waiting times in IAPT are rising.

Also increasing is the problem, which was just referred to, of commissioners focusing, through their financing arrangements, more on those who need the least help—the easiest to help who can be dealt with cheaply. There is a serious dead weight if you give the help to the people who least need it. That will increasingly go on under these financial pressures unless serious steps are taken to stop it.

What can the Government do? As the services are locally commissioned, the Government have no way to force local commissioners to spend the money that was set aside in their baseline for IAPT in the spending review. They do, however, have tools, the first of which is the central guidelines embodied in the NHS outcomes framework. This is what commissioners read. They cannot read all that paper and prose but they can read the one sheet that contains 60 outcomes for the NHS. Where does IAPT appear in those 60 outcomes? It does not. That is just not good enough.

Depression is 50% more disabling than most of the chronic physical illnesses that are now a big focus for the NHS. Depression and anxiety account for at least one third of all morbidity in Britain. The NHS is there to deal with the mass of morbidity in the country, so how can it possibly be that the main treatment for those conditions is not in the NHS 60 outcomes? I agree that this is not a conspiracy, but it is a failure which happens because mental health so often gets overlooked. Unless we have IAPT outcomes within the NHS outcomes framework, it is nonsense to be talking about parity for mental and physical illness.

We have waiting time targets for all physical conditions treated outside general practice, but there are no waiting time targets for depression and anxiety. That is not parity of esteem either. There is also a huge problem with local commissioners paying less and less for therapy, leading to a bias against those in greatest need. We need a central initiative and national tariffs if we are to secure parity of esteem for serious mental illness as against physical illness.

I must come, finally, to the question of the central leadership of the programme, which is, as I explained, why it has succeeded. The programme is only half way through its development but its present coverage is 10% compared to the 15% to which the Government are committed. Even then, the programme will not have touched most of the 3 million people with physical conditions who are also mentally ill. This problem has not yet been tackled, although it is costing the NHS a huge amount in the physical healthcare budget due to the comorbid mental condition. The estimate is that something like £10 billion a year of the NHS physical healthcare budget relates to comorbid mental conditions that ought to be treated. Big savings could be made from that. We claimed in our report that at least half a billion pounds could be saved by extending psychological therapy to that group. Extending IAPT on that scale would cost the NHS nothing in net terms. On top of that, it would save the DWP and the Treasury the money on benefits, which would again repay the cost of the therapy. However, none of this will happen without central leadership. It really is just like that. The question is: what is being planned for the central leadership of the programme next April, when it ceases to be housed in the Department of Health? So far, we have had no public word on that critical question.

There is a real risk of a disaster in the making, not intentionally but by mistake. I have to ask the noble Earl three questions—not to embarrass him, because I know his heart is in the right place. However, I get heartrending letters from people every week and there are millions of people out there whose lives are at stake in all this. If I might, I should like to end with the three questions. First, what plans do the Government have for the central IAPT leadership team? That really is crucial. Secondly, will the IAPT outcomes be incorporated in the outcomes framework? Thirdly, will the Government introduce rights to waiting times in mental health as in physical health? I hope that the noble Earl can help us on all these points, either today or shortly hereafter.

--- Later in debate ---

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

My Lords, I begin by congratulating my noble friend Lord Alderdice on securing this debate, and on raising the important issue of strengthening mental health in the NHS.

This is a timely debate. Wednesday is World Mental Health Day, a day which sends an important message across the global community: mental health is everyone’s business. As the noble Baroness, Lady Young, rightly emphasised, it is appropriate to turn the spotlight on mental health services at a time of huge structural and service reform across health and social care, when a lot of the attention has been focused on primary care and clinical commissioning groups. It is vital that mental health is woven in to the fabric of these reforms.

Before I respond in detail to the remarks made by my noble friend and other noble Lords, I want to take this opportunity to thank him and the noble Lord, Lord Layard, in particular for their lobbying, research, advice and support, which have done so much to set the standard for mental health services and drive system reform.

The recent report from the London School of Economics’ Centre for Mental Health, How Mental Illness Loses Out in the NHS, makes a compelling case for prioritising investment in mental health services and for treating mental ill health as seriously as physical ill health. Although we take issue with some of the content, we are in full agreement on these two central tenets of the report. Mental health simply cannot be an add-on or an afterthought. It costs £105 billion per year, to say nothing of the emotional toll that it takes on individuals, families and carers, so it must always be in the foreground when we think about health and social care. The messages are clear from people with mental health problems and their carers. They want to see a real difference in the range, quality and choice of services available. They want everyone to benefit from our mental health strategy, “No health without mental health”. This includes people with severe and enduring mental illness, those from minority ethnic communities and individuals who have offended.

They also want us to recognise the importance and expertise of family carers, who have so long occupied a shadowy position ill-served by legislation. This Government have committed themselves to fulfilling those wishes. Our new mental health implementation framework, coproduced with five leading mental health charities, sets out how we will do that. The framework translates the strategy’s vision into practical action for specific organisations. It outlines what the new health and care system will mean for mental health; and it shows how the mental health strategy fits with the three outcomes frameworks for the NHS, social care, and public health, and how each will help to deliver the other.

On top of that, the draft mandate to the NHS Commissioning Board, published for consultation on 4 July and mentioned by my noble friend Lady Tyler among others, also emphasises the importance of a new focus on mental health. This is reflected both in a dedicated objective on mental health, and in objectives for improving performance against the NHS outcomes framework. Overall the mandate suggests a culture-change on mental health throughout the NHS.

I simply say to the noble Lord, Lord Layard, that the Commissioning Board is discussing future arrangements with Ministers, but in the end, as he will recognise, it will be up to the Commissioning Board to deliver its commitments, and not for the department to second-guess the board. The noble Lord, Lord Layard, has said that the outcomes framework contains almost nothing on mental health. This is simply not the case. The 2012 framework contains three improvement areas which relate specifically to mental health—

[Lord Layard]

I was referring only to it containing nothing about the outcomes from IAPT, which is a very big service. There is nothing about recovery from depression and anxiety.

[Earl Howe]

I am grateful, and I will come on to that point. It is just worth rehearsing that there are three improvement areas: premature death in people with serious mental illness, the quality of life of people with mental illness, and the experience of healthcare for people with mental illness. In addition, many of the indicators relate to all patients and therefore apply equally to mental health patients. We are keen to strengthen the outcomes framework in relation to mental health in general, and recovery from mental illness in particular. We have recently begun work to define what good recovery from mental illness looks like, recognising that for some people this will mean the effective management of symptoms rather than a cure, and to develop proposals for how this might be measured. Our aim is develop measures that are suitable for inclusion in the NHS outcomes framework.

I know that some, like the noble Lord, Lord Layard, have been concerned that not enough is being done to meet the needs of people with long-term physical health conditions who also have mental health needs. We are addressing that. One of the measures by which we will gauge the success of the NHS Commissioning Board will be its ability to improve care for people with long-term conditions. This obviously includes people who have both physical and mental health problems.

Moving on to IAPT, we are also addressing the criticism that psychological services are too difficult to access in the first place. The operating framework for the NHS in England clearly states that the NHS should carry on expanding access to psychological services as part of the improving access to psychological services or IAPT programme. The noble Lord, Lord Patel of Bradford, said that change on the ground was hard to discern. The coalition Government have overseen a big increase in the number of people benefitting from IAPT services: 528,000 people entered treatment in 2011-12, more than double the number in 2009-10.



These new services are achieving recovery rates of more than 40% and are on track to meet recovery rates of at least 50%. We are investing £32 million this year in training new therapists to meet the demand. More than £400 million will be channelled towards talking therapies so that adults with depression and anxiety across England can get access to NICE-recommended psychological therapies. That investment will also help to fund the expansion of psychological therapies for children and young people—I shall say a bit more about that in a moment. We are also looking at how older people, carers, people with long-term physical health problems and those with severe mental illness can get better access to evidence-based psychological therapy.

Contrary to the statements quoted by the noble Lord, Lord Patel, we have no evidence of underinvestment by the NHS in IAPT services. On the contrary, funding is going up. At present, 149 out of 151 PCTs commission an IAPT service, which is nearly 100 services across England covering more than 95% of the population. However, in order to secure consistently good services, there needs to be a fundamental change in the way our society views mental health. Both individuals and organisations need to change some views that on occasion are deeply entrenched. We have commissioned the Royal College of Psychiatrists to look at how we can encourage everyone to ascribe the same importance to mental health and physical health. The work involves many leading royal colleges, professional associations, charities and others. It includes concrete examples of positive changes that parity would help to bring about. The college has already begun to collect and develop examples of both good and bad practice, and its final report will be available shortly.

My noble friend Lord Alderdice mentioned skills. It is important to note the influence that the royal colleges can wield in improving mental health services. The Royal College of General Practitioners has identified improved care for people with mental health problems as a training priority. It has proposed enhanced training for GPs, designed to increase clinical, generalist and leadership ability. I welcome its suggestion that mental health should be a central part of that enhanced training.

The GP curriculum and examination system will be changed to accommodate the new system of training, so we can look forward to newly trained GPs with an extremely broad knowledge of mental health issues. That is an excellent example of the role that groups outside government can play.

There have been a lot of stories about spending on mental health services being cut, but spending on mental health has stayed broadly level in cash terms. Although this has meant a very slight reduction when compared with inflation, this is quite an achievement given the huge cost pressures on the NHS and quite a different picture from the one that is often claimed.

My noble friend Lord Alderdice and the noble Lord, Lord Patel, questioned how we know that the £400 million is being spent on IAPT. The NHS is accountable to the department for results, not for spending money in line with predefined pots; it is outcomes that count. We have made sufficient money available to the NHS to maintain the expansion of IAPT. We have made very clear what results we expect from that investment, but local commissioners must be in a position where they decide how to use their budgets to meet the health needs of their local populations. That is not something that we can decide in Westminster.

The noble Lord, Lord Layard, and the noble Baroness, Lady Emerton, spoke about the slowing down of this effort. Preliminary figures for the first quarter suggest that the expansion of talking therapy services is slowing in some parts of the country. We are looking at the data to make sure that we understand whether that is temporary or something more serious, but it is clear that the picture is very variable across the country.

I have just received a note to say that my time is running out. I say now that I will write to all noble Lords whose questions I have not covered, but I shall in the time available cover as many more as I can, in particular on children’s services, which was a theme of my noble friend Lady Tyler and the noble Baroness, Lady Young.

Children’s mental health is a priority for this Government. The Government’s mental health strategy takes a life-course approach, recognising that the foundation for lifelong well-being is already laid down before birth and that there is much we can do to protect and promote well-being and resilience through our early years and adulthood. We have invested up to £54 million over the four years from 2011-12 to 2014-15 in evidence-based practice, such as children and young people’s IAPT, undertaken work to introduce payment by results for CAMHS, which my noble friend Lady Tyler referred to, and announced plans for a children’s health outcomes strategy.

Children and young people’s IAPT is a service transformation project for CAMHS, extending training to staff and service managers and embedding evidence-based practice across services to make sure that the whole service, not just the trainee therapists, use session-by-session outcome monitoring.

My noble friend Lord Alderdice and the noble Baroness, Lady Meacher, questioned whether there was a bias towards IAPT to the detriment of other services. Although I agree that there are different approaches to providing psychological therapies, it is local commissioners and not central government who are responsible for determining which services should be funded. I am happy to write on that theme, about which I have further information—as I do about charities, a point raised by the noble Lord, Lord Wills, who also asked me about the mental health legislation resource. I have a note that I would gladly have read out, but time has eluded me. I will also gladly write to the noble Lord, Lord Patel, about prisoners’ mental health and to my noble friend Lord Alderdice about patients being locked in at night at Broadmoor, as well as any other points that I have not covered. I am very grateful indeed to all noble Lords who have spoken in what has been a most illuminating and helpful debate.

Health and Social Care Bill

Lord Layard Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Lord Ribeiro]

My Lords, I will be brief on this. I strongly support the amendment because it is important to recognise that mental health and acute clinical health go hand in hand. Most hospitals throughout the country started with psychiatric services outwith the main hospital buildings. Over many years we have tried desperately to integrate the service. We no longer have the concept of the psychiatric Bedlam that was the case in the past.

For the last five years or so of my clinical practice, a rotation of junior doctors came to work for me. They would spend four months on general medicine, four months on surgery and four months on psychiatry. As a consequence, I learnt quite a bit about psychiatry, although I am not sure that they learnt an awful lot about surgery. That was an example of integrated care. The importance of it is that a lot of the acute psychotic and suicidal admissions to hospital come through the accident and emergency department. They do not come through the separate door of a psychiatric unit at the other end of the hospital or in a different block. They come to the acute part of the hospital.

I am not saying that the Bill team necessarily overlooked this but, as has been pointed out by the noble Lord, Lord Williamson, if proposed new subsection (1)(a) is to refer to the Secretary of State’s duty to and responsibility for “physical and mental health”, it stands to reason that, as is currently the case, the Secretary of State delegates responsibility for the provision of the health service to the strategic health authorities and PCTs. Their successor bodies will be the national Commissioning Board and the clinical commissioning groups, so it stands to reason that those two bodies must also have responsibility for mental and physical health. It is vital that the three major groups who have responsibility for the health service in this country—the Secretary of State, the NHS Commissioning Board and the clinical commissioning groups—should all have a responsibility to deal with these two areas of healthcare, because they form part of an integrated service.

[Lord Layard]

My Lords, some years ago I had a meeting with a newly appointed Secretary of State for Health, although he was not that newly appointed—he had been there for three weeks. At the end of our conversation about mental health, he said, “You know, I’ve just realised something. I’ve been in this job for three weeks, I’ve had about 50 meetings and this is the first time I’ve heard the words ‘mental health’”. That says it all. That is how our health service is run and, unfortunately, how the priorities are set. I should just like to review four key facts to show why this is not at all satisfactory.

First, according to the official survey, one in six adults suffers from mental illness, mainly clinical depression or crippling anxiety disorders. These are serious conditions, as has been said. For example, a very good WHO study compared the debilitating effect of depression with that of angina, arthritis, asthma and diabetes. Depression is at least 50 per cent more debilitating than those conditions. That is why half of all the disabled people of working age in our country are disabled by mental illness. It is not a small segment but a massive chunk. It is the largest illness among people of working age.

However, coming to my second point, only a quarter of those who are mentally ill are in treatment, compared with more than 80 per cent of those with the kind of physical illnesses that I mentioned. Last year the chairman of the Royal College of General Practitioners wrote to his members with the question: if you have a patient who needs psychological treatment, can you get it normally, sometimes or rarely? Only 15 per cent said “normally”. That is the situation that we are in, which is shocking. The treatments that are available are good. They are recommended by NICE but simply not delivered on a proper scale, even though they are meant to be delivered according to the NICE guidelines.

Thirdly, what is even more extraordinary is that these are cheap treatments. It is quite easy to show from the experience of the Improving Access to Psychological Therapy programme, for example, that they completely pay for themselves through savings on out-of-work benefits, lost taxes, unnecessary visits to the GP and unnecessary references to secondary care. However, if we ask what commissioners’ priorities are, these treatments are of lower priority than many of those for physical conditions that are often much less disabling.

Finally, what is so extraordinary about this, as other speakers have said, is that the problems of people with mental health difficulties also rebound on their physical condition. We also know that many physical conditions rebound on mental conditions. Many physically ill people—those suffering from angina, lung disease or a stroke, for example—suffer from depression. Several proper clinical trials show that, with proper psychological treatment of these mental conditions, the physical condition will improve to the extent that all the money is, again, repaid in savings in physical care. Therefore, we should give much more priority to these conditions.

We also see cases where people are referred with physical conditions that have no physical explanation. Something like half of all referrals to the secondary sector fall into that category of medically unexplained symptoms. Again, many of those will respond to psychological treatments.

Despite all this, we all know where mental health stands in the priorities of commissioners. It counts if there is a serious risk of homicide or suicide. Then they really get to it. However, if not, it is, unfortunately, the easiest area to cut, which is happening on quite a scale at the moment. Two years ago the regulator, Monitor, recorded the fact that mental health services are cut by more than physical health services whenever there is a shortage of money. Monitor recorded this in its advice to trusts on how to budget in the future; it was part of its guidance. It is invariably the case that mental health is cut more than physical health when there is a shortage of money. It is just extraordinary. That guidance was eventually recanted but it is the reflex throughout the commissioning world. I am making the point that this is not only important but a very big thing. That is why it is important that we include the phrase “physical and mental illness”, and do so from the beginning of the Bill. If we do not, people will tend to forget mental health, as the department did for three weeks when it was briefing the then Secretary of State. I urge the noble Earl to take this amendment very seriously.

[Baroness Murphy]

My Lords, I rise briefly to support the eloquent speech by my noble friend Lady Hollins and other noble Lords who have spoken in this debate, if only to give the House a hat trick from the psychiatrists who are here today.

In 1845 the Lunacy Act first separated physical and mental health with the building of the asylums. Before that, in the Poor Law Commission’s provision of service to the general population, around 30 per cent of the medical time of general practitioners and specialists who were engaged by the Poor Law Commission was spent on people with mental health problems and what we would call learning disabilities. That division, however good it was in developing the services in other ways, has led to a separating out which continued after 1948, to the detriment of the development of services.

This Government and their predecessor have done an enormous amount to right that imbalance. As I have pursued my career in psychiatry, I have seen a dramatic difference in the investment that has been made in mental health services. However, there is still a lack of parity and when people talk about illness they still mean physical illness. I do not know whether the wording “physical and mental” is quite right in this amendment. However, it seems to me that the time is right to have an explicit provision on the face of the Bill regarding the equal importance of mental health and physical health in building a healthy nation. Unless we address physical and mental health together, we will not improve public health. It would be a good time to get such a provision in this Bill as it moves forward with a new style of NHS. I hope the Minister agrees that this is too important a matter to let it go.

Health: Mental Health Strategy

Lord Layard Excerpts

Monday 14th February 2011 Lords Chamber

[Lord Layard]

My Lords, I, too, welcome the debate. It is extremely timely, because it is a time of great opportunity for mental health services but also a time of great danger, as many noble Lords have said. I should like to begin with the opportunity. We have here an excellent strategy which provides a better deal for mentally ill people, especially the one in six adults with depression or anxiety disorders and the one in 10 children with mental health problems. If we take those two groups, we are starting from a very poor base where only a quarter of those people are at present in any form of treatment. It is great that the Government are giving that group a major boost through a specific strategy, the Improving Access to Psychological Therapies programme. I must declare an interest as a national adviser to the programme.

In the spending review, the Government have backed the strategy, with £400 million allocated. This must be the first time that specific money for mental health has appeared in the top six priorities for health spending in a spending review. That is wonderful progress. It is also very satisfying that the spending has been extended to include CAMHS, the Child and Adolescent Mental Health Services. Of course, the task is to ensure that the money gets spent to good effect. A key issue here is the role of local commissioners. The NHS operating framework gives clear instructions because, for the first time, improved access to psychological therapy has been made a national rather than a local priority for local commissioners. Again, that is major progress. The framework also requires session-by-session monitoring of outcomes and reporting, so that commissioners can see what they are getting for their money in both access, where there is a clear standard of 15 per cent of the mentally ill population, and in the quality of service, represented by the recovery rate, which is intended to be at least 50 per cent of those treated.

However, it is important that those key performance indicators are made publicly available, because that is the only way in which local commissioners, as well as providers, will be held to account by the public. It is important that commissioners understand that they really have to do something to deliver the key performance indicators. Perhaps the most important thing that they have to do, which was assumed in the calculations for the spending review, is to make sure that providers are employing sufficient qualified therapists—at least 40 for every 250,000 population. We should consider those as some of the most important jobs in the country. It is very exciting that the Government have a training programme in parallel with local service delivery to provide that number of therapists and it is important that the local commissioners then ensure that they are employed. We are starting from a situation where the NICE guidelines for depression and anxiety simply cannot be implemented in at least 40 per cent of the country. But, if the spending settlement is properly implemented, the whole country will be covered by 2013.

This is a major challenge and a real revolution if it can be brought about. It is in everyone’s interest that it is, including the whole of the NHS, because the waste in the current situation is terrible. It is not just a waste of lives and taxpayers’ money: one can show that improved access to psychological therapy will pay for itself twice over as regards the taxpayer. First, it will save more in incapacity benefit and lost taxes than it will cost. Secondly, the programme will save the NHS as much money as it costs.

We have evidence, unfortunately, only from the US, but we also have good evidence from 28 randomised control trials of cognitive behavioural therapy. Data were collected on the cost of the therapy and the subsequent healthcare costs of those treated and of the control group. In 26 of the 28 trials, the savings in subsequent healthcare costs were greater than the cost of the initial therapy, which is a cast-iron case. However, the danger is that we are in a world of cuts. In all previous worlds of cuts, mental health expenditure has been cut more than physical health. The studies that I have quoted show how incredibly short-sighted that would be even in terms of the costs of physical health. It must not be allowed to happen again.

Finally, I want to ask the Minister two simple questions. First, is it government policy that mental health expenditure should be cut by no more than expenditure on physical health? Secondly, if that is their policy, what steps will the Government take to make sure that this is what happens? I think that these are the key questions which lie behind much of what noble Lords have said today. I hope that the noble Earl will be able to help us when he replies.