Care Bill [HL]

Lord Patel of Bradford Excerpts

Tuesday 21st May 2013 Lords Chamber

[Lord Patel of Bradford]

My Lords, the Minister has clearly outlined the many positive qualities in the Bill. Although I welcome many aspects of it, a number of issues cause me concern, particularly with respect to the care of some of the most vulnerable people in society—those with mental health problems.

I wish to explore four specific aspects of the Bill and seek assurances from the Minister about how the Government intend to address these: first, the lack of adequate safeguards for effective advocacy—for example, in ensuring take-up of personal budgets and protecting those detained under the Mental Health Act; secondly, what I see as unnecessary changes to the definition of mental health aftercare services; thirdly, how adult safeguarding boards will be able to exercise their functions effectively; and, finally, the lack of clarity about continuity of care for people in prison and on leaving prison.

I start with the new national eligibility criteria and personal budgets. Overall, I support the Bill’s focus on this and believe that giving everyone who is eligible access to a personal budget will greatly improve their lives. However, accessing these budgets is a far from simple process. For example, there are already significant variations in the take-up of personal budgets between councils and regions, and between different community groups. The official figures from the NHS information centre show that while 29% of adult care users or carers receiving community services had a personal budget in 2010-11, the rates ranged from 4% in Somerset to 71% in Manchester. The figures suggest that progress on moving people onto personal budgets is slowest in the south-west, where the average take-up is around 18%, and fastest in the north-west, at around 35%.

Moreover, the uptake of personal budgets among people with dementia still lags way behind most other client groups. The Alzheimer’s Society in a report in 2011 found that three in five people with dementia assessed as eligible for a care package were not even offered a personal budget, while 15% declined an offer of one. The report clearly highlighted the importance and need for advocacy or brokerage services and stated that,

“support planning and brokerage services are crucial to enable people to access the system”.

I fear that without a statutory entitlement to effective advocacy and support, some of the most vulnerable users and carers, such as those with mental health problems, learning disabilities and dementia, will not be able to access the system nor have their needs met through the kinds of informal support services that personal budgets are so good at enabling.

I am concerned that it was not considered necessary specifically to reference advocacy within the duty to provide information and advice. In meeting this duty, local authorities will be expected to provide information and advice that is accessible and proportionate to all. Of course, I recognise that an individual’s requirements for information and advice could range from a leaflet or a face-to-face conversation to long-term independent advocacy but, as the Law Society stated, “information … is no substitute” for a proper system of advice and advocacy for service users to navigate what will be a “complex system”.

Further, in a really important point, the Law Society notes that Clause 2(3) states that local authorities may be permitted to “make a charge for” this service and that this will be set out in regulations. I would like to know how vulnerable people who lack resources and in many cases live in poverty will find the means to pay for this. For those who are vulnerable and disadvantaged, charging could in fact become a new barrier to accessing an already difficult system.

What about those with mental health problems? The Bill rightly highlights the Government’s aspirations of achieving integrated and joined-up care, including parity of esteem between physical and mental health. This parity of esteem must include those detained under the Mental Health Act, where there is an even stronger case for the provision of effective and independent advocacy. I feel very strongly that unless all patients subject to compulsory powers under the Mental Health Act can access a truly independent mental health advocate, they will continue to be at risk of missing out on the most basic elements of care and support intended by the Bill. This is even more important for those groups already experiencing significant inequalities, such as those suffering from mental health problems who are from black and minority ethnic communities. It is crucial that we tackle these existing inequalities in the mental health system. I believe that providing effective and independent advocacy would be an essential step in doing this.

In fact, I am very concerned about the relative lack of focus on mental health in the Bill. Frankly, mental health is the biggest unaddressed health challenge of our age and is costing our society and the economy millions of pounds every day, not to mention the cost of the suffering among individuals and families. Why, given the critical nature of mental health problems, have the Government once again chosen to change the statutory provision of free aftercare services for people who have been treated under the Mental Health Act? I speak, of course, about Section 117 services, which noble Lords will recall this House debated to a large extent during the passage of the Health and Social Care Bill. Yet here we are again, faced with what I believe to be an unnecessary and possibly harmful change to these vital services. I will be seeking to make amendments in Committee unless the Minister can explain how these changes help or improve provisions which may not be perfect, but which ensure a degree of protection for those very vulnerable groups of people.

In particular, I am at a loss as to why the Government are attempting to change the eligibility criteria for Section 117 services. For example, Clause 68(5) introduces a new definition of aftercare services such that these services must be,

“meeting a need arising from or related to the mental disorder of the person concerned”.

This is surely unnecessary, but more importantly—and this gives me real cause for concern—given the history of local authorities in trying to avoid their responsibility for aftercare services of this kind, this new definition would enable local authorities to refuse aftercare on the basis that the need is no longer related to the mental disorder. Far from clarifying the position, this new definition adds to the complexity and risk, creating a situation where more people are denied access to these essential services.

I understand that the Government’s aim was to translate the Law Commission’s recommendation on Section 117 of the Mental Health Act into the draft Bill, but I note that the Law Society has asked for specific assurances that there is no intention by government to erode the current free-standing duty to provide free aftercare under Section 117 to,

“some of the most vulnerable”,

individuals in society. I suggest that the proposed new definition of aftercare services is too restrictive and could generate complex legal disputes over whether a service should be provided under Section 117. I will need a great deal of persuading that the proposed changes bring any benefit and do not in fact create the likelihood of greater harms.

Care of the vulnerable must be at the forefront of our efforts. Therefore I welcome the statutory framework for adult safeguarding, which includes the establishment of Safeguarding Adults Boards in local areas. The Bill states that these boards will be required to produce safeguarding plans and updates on progress, and that where a board “knows or suspects” that “serious abuse or neglect” has contributed to the death or serious harm of an individual, it will be required to carry out a safeguarding adult review.

However, I have a number of concerns and questions around how these boards will be able to exercise these functions effectively. For example, not only must local authorities and the NHS work together, but neighbouring local authorities must establish communication systems to ensure that all knowledge on abuse issues is shared not just in a local area but across areas, if another Winterbourne View is to be avoided. We also need avenues of communication for carers and families to register concerns, and for these to be looked at quickly. In fact, carers and families should not only have input on the boards but, I suggest, be supported to act as representatives on them.

Moreover, effective safeguarding work cannot be disassociated from other aspects of care and support provision. For example, with more and more people with higher needs potentially being employers with personal budgets, they will be vulnerable to abuse in their own homes. How will this be safeguarded against? There can be no doubt that for these boards to be effective, local authorities will require additional funding. Where is this to come from? I will not add to the many comments about lack of funding already made by other speakers; I simply pose the question again.

Finally, as I understand it, the whole point of this Bill is to move away from responding to crises and emergencies which can result in costly and unnecessary hospital or residential care. The aim is rather to develop person-centred and preventive approaches that meet real needs in a timely and appropriate fashion. One group who especially need this are those with social care needs who are entering or leaving prison. For this group, care is often not of the same standard as it would be in the community. In fact, a 2007 report by the University of Birmingham for the Care Services Improvement Partnership, Adult Social Care in Prisons: A Strategic Framework, identified major shortcomings in the provision of social care in prisons.

Clause 69 could be a very important step in addressing these shortcomings, particularly considering that around 70% of prisoners will have mental health and substance misuse problems. Providing this care can have a significant impact on reoffending and greatly enhance people’s ability to rebuild their lives on release. However, for such benefits to be realised, it is essential that there is continuity of care between prisons and the community. We need to ensure that prisoners have access to care that is equivalent to what is available in the community. People receiving care before entering prison should continue to receive such support, and any care provided while a person is in prison should be continued through the gate. Local authorities, prisons and probation services must work together to ensure that effective links are in place. I would like some reassurance from the Minister that this will indeed be an outcome from the Bill and one that he recognises is important.

Many aspects of this Bill are welcome and are long overdue. However, there are significant omissions and there is a real risk that in the current economic climate and with the background of funding cuts, nothing will really change. I am concerned about those who are most vulnerable and whether we have truly learnt the lessons from Winterbourne View and Mid Staffs. If we continue to react to problems rather than resolving them at an earlier and more effective point, we will place the most vulnerable in our society at risk. I hope that the Minister will reflect on my concerns and respond appropriately.

Health: Mental Health

Lord Patel of Bradford Excerpts

Wednesday 21st November 2012 Lords Chamber

[Earl Howe]

My Lords, we expect the equal priority for mental and physical health to be reflected in all relevant aspects of the NHS’s work. There can be no single measure of parity. As I said earlier, we expect the board to be able to demonstrate measureable progress towards parity by 2015. However, there are some specific areas where we expect progress; for example, relevant measures from the NHS outcomes framework, including reducing excess mortality of people with severe mental illness; delivering the IAPT programme in full and extending it further; addressing unacceptable delays, and significantly improving access and waiting times; and working with others to support vulnerable and troubled families. Those are very detailed objectives for the board, all of which bear upon the key question of parity between mental and physical health.

[Lord Patel of Bradford]

Given the real terms drop in mental health funding last year, which was even greater for older people’s mental health services—an area which has many challenges ahead for us; will the Minister tell us how the Government will ensure consistency and parity in local commissioning strategies, as clinical commissioning groups can obviously choose to prioritise or exclude what they want to have in those strategies? How will the Government deliver the Prime Minister’s dementia target?

[Earl Howe]

My Lords, the way in which mental health services are commissioned locally is of paramount importance. One of the features of the reforms is to bring together local authorities and the health service to plan services in a much more integrated way. Clinical commissioning groups will ignore the imperative of mental health at their peril, because they will be charged—under the commissioning outcomes framework, which the board will set—to deliver meaningful progress on all the indicators, including mental health indicators. It is an absolute necessity that good commissioning takes place at a local level.

NHS: Evidence-based Medicine

Lord Patel of Bradford Excerpts

Wednesday 10th October 2012 Lords Chamber

[Lord Patel of Bradford]

My Lords, the UK is blessed with an excellent evidence base on the treatment of drug misusers. Can the Minister reassure the House that government policy around illegal drug use and treatment for drug users is based on that evidence base and not on what appears to be a policy direction of abstinence only and punishment for drug users?

[Earl Howe]

My Lords, yes I can. There is a real impetus within Government to look at evidence-based treatment for illegal drug users.

NHS: Mental Health Services

Lord Patel of Bradford Excerpts

Monday 8th October 2012 Lords Chamber

[Lord Patel of Bradford]

My Lords, I too add my thanks to the noble Lord, Lord Alderdice, for tabling this important and timely debate. The noble Lord has made and continues to make an immense and important contribution to this area of healthcare in terms of its development and delivery. Like him, I believe passionately that we must do a great deal more to address the needs of people who suffer from mental health problems.

The question before us today is how do the Government intend to strengthen the provision of mental health services in the NHS? It is a vital question at a time when the NHS is facing the most significant upheaval in its entire history and the finite resources we have for healthcare are being further reduced.

When the coalition Government first came to power I was very pleased to see mental health given priority attention. Those earlier efforts to raise the profile of mental health problems were very much welcomed, in particular their strategy No Health Without Mental Health, although I think I prefer the title of the noble Baroness, Lady Emerton. The Government have continued to invest in talking therapies and we have seen the excellent anti-stigma campaign Time to Change. However, I have to ask myself what is really changing? What lies beneath all the rhetoric and good intentions? The problems are certainly not getting any less.

My noble friend Lord Layard talked about his recent report published by the London School of Economics that sets out some of the starkest evidence that I have seen that the problems are getting worse. More significantly, as we see increasing levels of problems, we do not see a similar rise in treatment services. The report clearly outlined that mental illness is now nearly half of all ill health suffered by people under 65 and it is more disabling that most chronic physical disease. Yet, only a quarter of those involved are in any form of treatment. Mental illness also accounts for 23% of the total burden of disease. Yet, despite the existence of cost-effective treatments, it receives only 13% of NHS health expenditure.

There are currently six million people with depression or crippling anxiety conditions, and more than 700,000 children with problem behaviours, anxiety or depression. The noble Baronesses, Lady Tyler and Lady Young, raised the important issues with respect to these children. However, most of these people receive no treatment because, as the report says:

“NHS commissioners have failed to commission properly the mental health services that NICE recommend”.

The report concluded:

“The under-treatment of people with crippling mental illnesses is the most glaring case of health inequality in our country”.

It is a shocking form of discrimination because effective psychological treatments exist but are still not widely enough available. What steps are the Government taking to address this health inequality and to ensure that local authority and NHS commissioners do commission mental health services in line with NICE recommendations?

It is very clear that we cannot allow this situation to continue. At a time when the economy continues to struggle it is vital that these issues are addressed, because the lack of adequate mental health provision is threatening the chances of our economy recovering. For example, recent research shows that one in 10 workers has taken time off work because of depression. The MORI poll that identified this figure was conducted across seven European countries involving more than 7,000 people. Overall, 20% of those polled had received a diagnosis of depression at some point in their lives and, shockingly, the highest rate was in Britain, where 26% had been diagnosed. Among workers experiencing depression, 58% in Britain were most likely to take time off. Surely, in view of these facts, the Government need to rethink cuts to mental health care and should be looking to expand care instead.

Notwithstanding the comments made by the noble Lord, Lord Alderdice, about therapies, evidence has shown that the cost of psychological therapy is low and recovery rates are high. Expenditure on psychological therapies for the most common mental health problems is also cost effective as long as we take heed of the comments made by the noble Baronesses, Lady Meacher and Lady Tyler, about the need for consistency, quality and choice of services. For example, when people with physical symptoms receive psychological therapies, the average improvement in physical symptoms is so great that the resulting savings on NHS physical care would outweigh the cost of psychological therapy—a point made clearly by my noble friend Lord Layard.

It was for these reasons that the Labour Government started in 2008 the six-year IAPT programme. We know that in areas where this has been effectively commissioned, it has had a positive impact. However, we also know that the £400 million earmarked by the coalition Government for psychological therapy has not always been used for its intended purpose because there was no commitment on NHS commissioning managers to do so. It is essential that that programme is completed as planned, since even this will provide for only 15% of need.

What about those with more complex and enduring mental health problems? Let us not forget that when we are talking about strengthening NHS services, this includes services provided in prisons, where we know there are very high numbers of people with mental health and substance misuse problems. In fact, the annual report to Ministers by the independent monitoring board at HMP Pentonville reported that health and social care workers providing health support to inmates are being stretched by a “serious and sharply increasing” rise in demand for care. The report stated that mental health teams at the prison received 24 referrals a week in 2011-12, up from 18 a week the year before. Incidents of self-harm had also increased “very significantly” over the past year. The prison’s 22 in-patient beds, the majority of which are used for mental health patients, were full to capacity. The report said that the reasons behind the spike in mental health demand at the prison were “not fully understood”, and warned that,

“further resources are urgently needed to tackle these issues”.

What will the Government do in response to this report to address the urgent health service resource needs in prison to tackle complex mental health issues?

When we are talking about vulnerable groups, we know that people from black and minority ethnic communities face specific difficulties, including higher rates of mental illness in some groups and problems with access to the right care and treatment—issues raised by the noble Baroness, Lady Young. Service user groups have expressed fears that funding provided to local user-led mental health groups, where some of the best progress has been made in black and minority ethnic mental health service user involvement, may especially be vulnerable when services are looking to make significant economic savings.

I share these concerns especially in light of the establishment of more generic service user involvement mechanisms such as Healthwatch England and local Healthwatch organisations. These cannot and must not be seen as a replacement for involvement mechanisms especially for mental health service users, and especially not for those that engage black and minority ethnic communities and have a rights-based focus capable of addressing issues in relation to the use of compulsion under mental health law. What specific steps are the Government taking to ensure that vital local user-led mental health groups are being maintained alongside Healthwatch and not being replaced by them?

In conclusion, it has been said that the challenge of mental health should be placed at the heart of Government but I suggest that where it really needs to be is at the heart of the new commissioning structures within clinical commissioning groups and local authorities. But as the NHS has clearly failed to commission mental health services in line with official guidance, and with further pressures to come on the whole NHS budget, will commissioners be able to take the action that is needed on securing and developing mental health services? I greatly fear that mental health services will continue to be the Cinderella services and that the urgency of need and the benefits that can be realised are not fully understood within these new and as yet untested commissioning structures. My final question to the Minister is: what will the Government do to ensure that clinical commissioning groups and local authorities address the full range of needs for mental healthcare in their commissioning plans?

Drugs: Prescribed Drug Addiction

Lord Patel of Bradford Excerpts

Thursday 12th July 2012 Lords Chamber

[Lord Patel of Bradford]

My Lords, while there certainly is a focus on recovery for illegal drug users, does the Minister agree that the journey from being a drug user to becoming “recovered”—that is, to abstinence—is very complicated? It may require that person to have treatments, including methadone, Subutex and other drugs. It is not simply a matter of someone becoming abstinent, especially in the current economic climate. Does he agree that that is still the direction of travel?

[Earl Howe]

Most certainly yes, and that conforms to all the expert advice that we in the department and local commissioners have received.

Health and Social Care Bill

Lord Patel of Bradford Excerpts

Monday 19th March 2012 Lords Chamber

Moved by

[Lord Patel of Bradford]

1: Clause 8, page 4, line 17, leave out “promoting equality of provision” and insert “reporting on and reviewing the treatment of providers”

[Lord Patel of Bradford]

My Lords, I speak to Amendments 1 to 6 in respect of Clause 8 of the Bill. As noble Lords will no doubt have realised, Amendment 1 is slightly different from the one that was debated on Report and I will explain why my noble friend Lord Noon and I have tabled it.

VAT recovery for charities is an important issue and one that has received considerable support. Indeed, my previous amendment to the Bill was passed. I will not repeat all the arguments made on Report but given the changed nature of the amendment I feel I should explain some of the differences.

I am very indebted to Sue Ryder Care for its support and invaluable information in preparing this amendment. It stems directly from its campaign, which started in 2011, to raise awareness about the problem of irrecoverable VAT for charities providing healthcare services. For example, the NHS is able to recover VAT on certain non-business supplies that charities cannot. This may hinder them from taking full advantage of the Government’s agenda, which will see more services outsourced from the NHS to other providers. It can be seen as a significant barrier to entry for charities which may be forced to use their charitable funds to pay the VAT.

--- Later in debate ---

[Earl Howe]

My Lords, I am pleased to conclude what has been a very good and constructive debate. I am extremely grateful to the noble Lord, Lord Patel of Bradford, for raising these important issues, both now and in Committee. As he stated, since his original Amendment 46 was introduced in Committee, we have worked together on this alternative amendment. While this has to some extent been a joint venture, all credit for the inspiration behind it must go to the noble Lord—along with the noble Lord, Lord Noon, whose strong commitment to the charitable sector is well known.

I can add little more to what the noble Lord has said, but it might be helpful to clarify a small number of points. First, I reassure the House that the Government are committed to a fair playing field for all providers of NHS services. We are particularly keen for voluntary sector organisations and social enterprises of all types and sizes to be involved. These providers are often among the most innovative and can offer highly personalised and bespoke services that meet the needs of local people. We understand that it is not just charities but the full range of voluntary sector providers—mutuals, co-operatives and social enterprises—that noble Lords are keen to see delivering NHS services. The new amendment enables a fair, transparent and impartial consideration of the issues, addressing all providers and possible means of responding to their concerns. I can confirm that the full intention is to look at how existing barriers can be removed, not to create new obstacles.

Secondly, as noble Lords are aware, a variety of barriers affect different providers. This includes not only payment of taxation but also access to and the cost of capital, the difficulty of securing appropriate insurance and indemnity, and the difficulty of bidding due to the scale or scope of contracts. The amendment therefore relates to a review of the full range of issues that affect the ability of providers or potential providers to deliver services for the NHS. I am sure noble Lords will agree that the potential is truly enormous.

We are clear that this is an important issue, which is why we want the report to be statutory and therefore accountable to Parliament and produced within 12 months of Royal Assent. Equally, it is crucial that the duty for the Secretary of State to keep these matters under review is in the Bill.

I can also assure noble Lords that the preparation of the report will involve full engagement with providers from all sectors, commissioners, and other stakeholders, such as Members of this House, to ensure that the full range of issues are considered and each of the concerns addressed. In particular, it will ensure that concerns around treatment for VAT of supplies of healthcare services or associated goods to the NHS by charities, including hospices, are considered. In response to the specific question of the noble Lord, I can confirm we would not see this review as in any way being slanted towards giving private sector firms a ‘leg up’.

This review will look at the barriers to achieving a fair playing field, and recommend actions to be taken to address them. We are already well aware that a number of the most deep-seated barriers affect voluntary sector providers, not those from the private sector. While I would not want to prejudge the result of the review, I fully expect that it will put forward a number of actions which could be taken to remove such barriers, thereby better enabling third sector providers to compete fairly with other providers of NHS services. I hope this reassures the noble Lord that, while I think we should look across all providers, it is our view that barriers facing voluntary sector providers are greater than those facing the private sector and we expect the review to focus accordingly on those.

I turn to the separate but related issue raised by my noble friend Lord Newby. We have also listened to the matters raised in other debates during this Bill and during the passage of the Public Services (Social Value) Bill, about the need to take social value into consideration in public sector procurement more generally. The Government agree that a wide-angle lens on the extended social, economic and environmental benefits when conducting procurement exercises can only be helpful. Today I am going further and put on the public record that the Secretary of State for Health is committing that the requirements in the public services Bill will be fully applied in relation to commissioning of NHS services through the procurement guidance that the board will produce on this. These were issues that were raised very compellingly by the noble Lord, Lord Mawson, and I pay tribute to him for his powerful and consistent advocacy on this theme.

I hope very much that your Lordships will find the amendment of the noble Lord, Lord Patel of Bradford, agreeable and I will be happy to support it.

[Lord Patel of Bradford]

I am very grateful for the Minister’s support in this and for taking it a lot further than I had done initially. I have learnt an enormous amount while we have been discussing these issues and I am sure that the not-for-profit sector will be very grateful for the support provided by the Government on this issue. I am sure it will raise a number of very important factors that will improve service provision for those areas.

Amendment 1 agreed.

Moved by

[Lord Patel of Bradford]

2: Clause 8, page 4, line 18, leave out from beginning to second “the”

--- Later in debate ---

[Earl Howe]

My Lords, I shall speak also to the other amendments in this group: 12, 13, 15, 16 and 18-29. During Report, the noble Lord, Lord Patel of Bradford, tabled an amendment to Clause 40, then Clause 39, relating to Section 117 mental health after-care services. Noble Lords will recall that in recognition of the strength of feeling on this issue, we did not oppose the noble Lord’s amendment. In the same spirit, we have now brought forward a set of consequential amendments resulting from the noble Lord’s amendment. Some of these simply tidy up the wording of the Bill as a result of the noble Lord’s amendment. Others are positive amendments to ensure that those receiving services under Section 117 of the Mental Health Act 1983 are not inadvertently excluded from benefiting from other provisions in the Bill. Specifically, the amendments ensure that Section 117 services are included in determining payments for quality; in special reviews and investigations by the Care Quality Commission; in emergency preparedness planning; in local authority scrutiny of the NHS; in NICE quality standards; and in information standards and information gathering. They also ensure that Section 117 services can continue to be available through direct payments.

I am pleased that the noble Lord, Lord Patel, has welcomed these amendments, and I hope that other noble Lords will agree that it is important that Section 117 services are included in all of these cases and will support these amendments. I also take this opportunity to ask noble Lords to support two minor and technical amendments. These remove an uncertainty about the breadth of the meaning of the reference to the Public Services Ombudsman for Wales in Clause 184, by clarifying that independent advocacy services extend only to certain complaints to that Ombudsman. I beg to move.

[Lord Patel of Bradford]

My Lords, I am obviously very happy to add my name to the amendments tabled by the Minister in respect of Section 117 of the Mental Health Act, pertaining to after-care services. I was grateful to the noble Earl and to the noble Baroness, Lady Northover, for not opposing my amendment on this issue. It somewhat caught me off-guard, but I was pleased with that. I was particularly pleased that we have continued to work together to add these technical adjustments today. To remind noble Lords: Section 117 requires primary care trusts and local authority social services to work jointly in providing vital after-care services. These types of services can vary a great deal, including visits from the community psychiatric nurse, attending a day-care centre, administering medication, providing counselling and advice, and most importantly supporting accommodation within the community.

Section 117 provides crucial protection for vulnerable people because it ensures that their local primary care trusts and local authority provider supply that after-care package in an appropriate way, including sorting out the funding on an agreed basis. This means that these essential services cannot be taken away until both the PCT and local authority, in consultation with the patient and their carers or the voluntary sector—the people who are supporting some of these patients—are satisfied that the patient no longer needs their services. The original concern that the noble Lord, Lord Adebowale, and I had was that Section 117 after-care was being unnecessarily diluted, as a joint duty to provide after-care was being changed. To all intents and purposes, Section 117 would have been treated as a duty under Section 3 of the NHS Act, and that would potentially have opened up the possibility of charging.

The noble Earl has laid out the protections set out in additional amendments and they are to be welcomed. They go beyond my original concerns and address a number of important issues. I will not list those listed by the noble Earl, but I was happy about the part of Section 117 arrangements that fall under the remit of the Care Quality Commission, ensuring that the regulator and monitor of services should look across patient pathways. I am particularly pleased about the amendment that ensures that Section 117 services are eligible for direct payments. This is a positive step, because it means that people detained under the Mental Health Act can take more control of the services that they receive after their release.

This is not only the right thing to do, as it will empower people who have been affected by being detained, but it is also likely to help to avoid readmissions by ensuring that people are more satisfied and engaged with services. We still have a long way to go to improve services for people detained under the Mental Health Act; in particular the experiences and outcomes when they return to the communities where they live. However, these amendments are a definite move in the right direction and I must congratulate the Minister for having the foresight and good grace to bring these amendments before the House. I wholeheartedly support them.

[Baroness Finlay of Llandaff]

My Lords, in this group of amendments there are two that relate to Wales. On behalf of the NHS in Wales, I am most grateful for the clarification. Could the Minister confirm that the Public Services Ombudsman would deal with complaints by any provider who is providing services for and on behalf of the NHS, irrespective of whether that is an NHS provider or a non-NHS provider? It would be helpful to have that clarification.

Health and Social Care Bill

Lord Patel of Bradford Excerpts

Wednesday 29th February 2012 Lords Chamber

Moved by

[Lord Patel of Bradford]

136A: Clause 39, leave out Clause 39 and insert the following new Clause—
“Aftercare
(1) Section 117 of the Mental Health Act 1983 (aftercare) is amended as follows.
(2) In subsection (2)—
(a) after “duty of the” insert “clinical commissioning group or”,(b) omit “Primary Care Trust or” in each place it appears,(c) for “such time as the” substitute “such time as (in relation to England) the clinical commissioning group or”.(3) After subsection (2C) insert—
“(2D) Subsection (2), in its application to the clinical commissioning group, has effect as if for “to provide” there were substituted “to arrange for the provision of”.
(2E) The Secretary of State may by regulations provide that the duty imposed on the clinical commissioning group by subsection (2) is, in the circumstances or to the extent prescribed by the regulations, to be imposed instead on another clinical commissioning group or the National Health Service Commissioning Board.
(2F) Where regulations under subsection (2E) provide that the duty imposed by subsection (2) is to be imposed on the National Health Service Commissioning Board, subsections (2D) and (2E) have effect as if references to the clinical commissioning group were references to the National Health Service Commissioning Board.
(2G) Section 272(7) and (8) of the National Health Service Act 2006 applies to the power to make regulations under subsection (2E) as it applies to a power to make regulations under that Act.”
(4) In subsection (3)—
(a) after “section “the” insert “clinical commissioning group or”,(b) omit “Primary Care Trust or” in each place it appears, and(c) after “means the”, in the first place it appears, insert “clinical commissioning group or”.(5) In consequence of the repeals made by subsections (2)(b) and (5)(b), omit paragraph 47 of Schedule 2 to the National Health Service Reform and Health Care Professions Act 2002.”

[Lord Patel of Bradford]

My Lords, it is with a heavy heart that I find myself speaking here again on this amendment, which attempts to make changes to Clause 39. This amendment is not about politics and is not in opposition to this troubled Bill; it is about the protection of the vulnerable and those in greatest need. I set out in some detail in Committee the reasons and purpose for my amendment, which had the support of not only many Members of this House from all sides but also many leading mental health organisations in this country, such as Mind, Rethink, the Mental Health Foundation, the Centre for Mental Health, the Law Society and the Royal College of Psychiatrists. These are not agencies with vested interests; they do not gain anything from fulfilling their core purpose, which is to advocate on behalf of those who are less able to speak for themselves as a consequence of severe mental illness. We are talking about people who have suffered from severe illness—those who have been so ill and at such risk that the full powers of the Mental Health Act 1983 were used to detain them and keep them in hospital.

These are not lifestyle problems; these are not people who could have chosen a different path. They did not choose to be detained in hospital, sometimes for very long periods of time. No—these are people whom the state, in making use of its considerable powers under the Mental Health Act, has a very clear obligation and duty to protect. That protection must go beyond the time spent in hospital to include their aftercare under Section 117 of the 1983 Act. One crucial thing about that section is that it requires primary care trusts and local authority social services to work jointly together in providing aftercare. This could include a variety of necessary things such as visits from a community psychiatric nurse, attending a day centre, administering medication and providing counselling services—or, most importantly, providing supported accommodation within the community.

Under the current law, a mental health patient can expect that their PCT and local authority provide the aftercare package in an appropriate way, including sorting out the funding between themselves. These vital services cannot be taken away until the PCT or local authority are satisfied that the person no longer needs them. I am not suggesting that Clause 39 would stop the provision of aftercare. What I am saying, and what many other experts in mental health and the law are saying is that that will have profound effects on how that aftercare is delivered and paid for, effects that fall down like dominoes with insidious and devastating impacts. For example, the clause removes the duty of co-operation in delivering aftercare services between the health service, the local authority and the voluntary sector, which makes what is a freestanding duty into a gateway provision. As a consequence, it provides a backdoor route by which aftercare services for detained patients will become chargeable.

I am grateful to the noble Baroness and the noble Earl for making time to meet the noble Lord, Lord Adebowale, and me to discuss our concerns. Unfortunately, this has been to little avail since, as your Lordships can see, there is no change to this clause. With the greatest of respect, I have to say that the Minister and indeed the officials in the Department of Health do not understand the full import of the changes that will be brought about by this clause. At least, I hope it is a misunderstanding because I am at a complete loss as to why our concerns have not been addressed.

Let me briefly give some examples of why I believe this clause will be so damaging. I take these from the Local Government Ombudsman, who became involved following several complaints about the application of the current law. I will explain why this is important in a moment, but let me first give your Lordships some of the detail of these cases. The first concerns a woman, Mrs Wilson, who, following a period of detention under the Mental Health Act, required care in a residential home as part of her jointly agreed aftercare. Yet despite the clear meaning of Section 117 of the Mental Health Act she was charged by the local authority for this care, resulting in the loss of her home. She was also discharged from a Section 117 agreement without her or her mother Mrs Walton, who was her main carer, being either involved or consulted in the decision, which was yet another breach of the clear meaning of the Act. The ombudsman found that the local authority had failed in its duty to provide aftercare, and in its duty to consult the patient and their carer.

The exact same issue—a failure to involve people in decisions, and inappropriate and illegal charging for services—arose in several other cases, such as with Mr Hughes’s sister, who was placed in a care home after being discharged from hospital, again under a Section 117 agreement. She, too, was charged for the costs of her social care and lost her home as a result. Despite clear advice from the Department of Health about Section 117 services being free, the council continued to apply charges. The ombudsman decided that,

“the Council’s delay in changing its policy amounted to maladministration, and that there was no reason why, with reasonable diligence, the policy could not have been changed some two years earlier than in fact it was. And this was a case where such diligence was required”.

It most certainly is required. I could go on and give many examples. The lady in question was being charged £256 a week for her aftercare, even after the legal advisers at the time said that this should have been free. At the time of the ombudsman’s decision, Mr Hughes’s sister had in fact paid costs amounting to £60,000.

Why are these cases so important? It is because they illustrate, even with the protection of the freestanding duty, that local authorities sought to break their agreements without consultation and did everything in their power to charge the people in their care for services that should most certainly have been free. That is the key to the issue in this argument. If this is how local authorities are applying the current law, what can we expect when they are freed from the duty of this care as Clause 39 seeks to do? They did that in a time of plenty, so what shall we see in the current challenging economic climate? What then for the vulnerable people who are coming out of hospital after having been detained under the Mental Health Act?

My amendment is about ensuring that this does not happen, and that even though it is not perfect we keep the joint duty, so that aftercare can be recognised and responded to in ways that are appropriate and necessary. The Minister has argued that this is about tidying up and aligning the legislation. It is exactly that alignment—that so-called tidying up—that causes the problems. I am reliably informed by legal advisers that introducing reference to the 2006 NHS Act in the way that this clause does will import into Section 117 the power to charge for aftercare services whenever the 2006 Act allows for it. I am in agreement with the noble Baroness, Lady Murphy, who asked in Committee, “What is wrong with the current situation? Why change what are clearly essential arrangements without some serious reasons for the change”?. This does not mean just a tidying up.

My amendment is simple. It retains a clear and unambiguous responsibility on clinical commissioning groups and local authorities to provide appropriate aftercare services. It will retain these duties on the basis that CCGs and social services authorities must act together jointly. It would also ensure that CCGs continue to arrange for the provision of aftercare services under Section 117, in co-operation with the relevant voluntary agencies. Most importantly, it preserves the judgment of the Law Lords of this House in the Stennett case that this is a freestanding duty, and as such cannot be used for the charging of aftercare services under Section 117.

As I said at the start, I move this amendment with a heavy heart because we should never have come to this point on this clause. I am not making trouble and this is not about making political points, but the Government make their case for this Bill so much harder by refusing to listen to those who perhaps know something more about the impact on people's lives, especially those who are marginalised and at serious risk. The current joint duty is essential, because it means that the patient is more likely to get access to the right kind of integrated health and social care services which they need and, most importantly, that the patient has an enforceable right to those services.

Aftercare under Section 117 is free of charge because the people who need these services are incredibly vulnerable and face a very real risk of relapse or self-harm, and of becoming more isolated and vulnerable as a result of not being adequately housed in an environment that offers them the protection they so desperately need. I will not retreat from this. My duty to those who are in such critical need of our support and my conscience will not let me retreat from this. I move this amendment in good faith and I hope that the Minister, whether it is the noble Earl or the noble Baroness who replies to this debate, will accept it.

[Lord Adebowale]

My Lords, I support the amendment moved by the noble Lord, Lord Patel. I am grateful to the noble Earl for the time that he generously gave to me and the noble Lord to meet him and the civil servants. However, I was disappointed by the letter that we received following the meeting. I thought that we had driven home the point and had some sympathy from the noble Earl. I understand the need to tidy up legislation, which is an important thing to do, but I find it faintly disgusting that we are going to mess up people's lives. The legislation might be neater but lives will be made much messier.

I have just come from Manchester—from Turning Point’s offices there; and I declare my interest as the chief executive of an organisation that will be directly affected by the Bill—where we have a case of an elderly lady who has been with us for 14 months, at a cost of well over £100,000. We cannot get the NHS to pay it because it claims that it is the responsibility of the local authority, whereas the local authority claims that it is the responsibility of the NHS. That is the reality under the current legislation, even with, as the noble Lord pointed out, the provisions of Section 117.

We are told that, in tidying up, the proposed provisions will allow people who are discharged from mental health institutions to seek a judicial review if they are refused aftercare arrangements in co-operation with health and social services. I was astonished to read that in the letter. I do not know what planet the writer of the letter is on but I would welcome them to join my planet and actually visit and speak to people who are discharged from these institutions, and to talk to their families and friends, and then to come back and tell me whether they are in a fit state to seek judicial reviews against local authorities and the NHS. We must be real when discussing legislation that will affect the lives of real people who may not sit in this Chamber but who will cost us a fortune if we do not get this right.

It is with a very heavy heart that I support the noble Lord, Lord Patel, in his amendment. I hope that, at this late stage, the Government will see the obvious logic. Even in their responses to previous amendments they said that they wished to support the joined-up provision of health and social care. What better example is there of such provision than Section 117 of the Mental Health Act? It is as obvious as gravity. So we must insist—not to make a political point or reference to the Bill, but on behalf of people not in this Chamber who will cost the country dearly if we do not get it right—that the Government accept the logic of the amendment and just say yes.

--- Later in debate ---

[A noble Baroness]

Now you have to go over and give her a kiss.

[Lord Patel of Bradford]

I was about to take my jacket off—

[Lord Beecham]

Just stop there.

[Lord Patel of Bradford]

But a hug is probably more appropriate. That is really good news; I am pleased that the Minister and the noble Earl, who I knew was sincere in all the discussions that we had, have accepted this important amendment. Of course I shall formally withdraw the amendment—

[Noble Lords]

No!

[Lord Patel of Bradford]

Sorry, I have lost my flow completely. I meant that I shall formally move my amendment. However, I would like to reserve the ability to see those technical changes and come back if they do not quite achieve what we want.

Amendment 136A agreed.

Organ Transplantation

Lord Patel of Bradford Excerpts

Monday 27th February 2012 Lords Chamber

[Lord Davies of Coity]

My Lords, can the Minister—

[Lord Patel of Bradford]

My Lords, while we have seen an improvement over the years in the number of donors from minority and ethnic groups, particularly the south Asian community, for a whole host of reasons, including religious and cultural matters, the number of donors needed to come through the system remains very short of what is required. What are the Government doing to improve the situation?

[Earl Howe]

The noble Lord is quite right: 75 per cent of people from a BME background refuse to donate organs when asked to, compared with an average figure of 40 per cent across the population. We are completely committed to increasing organ donor rates among the BME population, and there has been funding to support specific projects to work with local faith leaders and explore issues around organ donation. We held a workshop on 7 February with national and local groups to identify the barriers that exist in the BME and mixed-race communities, and plans are being developed to take forward that work. We have public awareness campaigns on local radio stations and through organisations such as the African-Caribbean Leukaemia Trust.

Health and Social Care Bill

Lord Patel of Bradford Excerpts

Monday 14th November 2011 Lords Chamber

[Earl Howe]

My Lords, I begin by saying that I completely understand the seriousness of the issues raised by the noble Lords, Lord Patel of Bradford and Lord Noon, and others noble Lords. The noble Lord, Lord Patel of Bradford, suggested that part of his purpose was to ensure that this issue remained on the government agenda. Let me assure him that the issue is very firmly on the Government’s agenda, and I am pleased that we are having this debate today so that I can outline exactly what we are doing.

Before I turn to address the amendment, I think it would be helpful if I briefly laid out the Government’s view of the role of the voluntary sector in the NHS. We firmly believe that voluntary sector organisations have a strong and often crucial role to play, due to the experience, expertise and insights that they can offer to commissioners and the system more widely. I of course acknowledge and pay tribute to the valuable work performed by Sue Ryder and numerous other charities, including most especially hospices. We recognise that they can play a vital role in delivering innovative, high-quality user-focused services in their local communities, along with improved outcomes for patients and increased value for taxpayers. We also acknowledge, as Amendment 46 highlights, that taxation treatment is one potential barrier to voluntary sector organisations’ entry into the provision of NHS services and to their increased involvement in those services. Access to capital is another. We are very keen to explore ways to overcome these challenges. The department is discussing this, as part of a wide range of issues, with voluntary sector providers of NHS-funded services.

When I was preparing for this debate, I asked whether the Treasury was looking at these issues, and the answer is that it is. I understand that Treasury officials are already working with representatives from the voluntary sector to explore the value added tax treatment of charities supplying the NHS, taking into account the legal limitations and the potential complexities around possible solutions. We are keen that they should make speed over this. However, the introduction of an artificial one-year timetable, as this amendment proposes, would limit the scope for a full and thorough discussion and consideration of this issue. I cannot commit to that limitation. However, I emphasise that we are very keen to work at possible solutions as fast as we can. It is a complex issue. My noble friend Lady Barker pointed us towards some of those complexities.

It is worth my repeating a general point here. The Government are committed to fair competition that delivers better outcomes and greater choice for patients and better value for the taxpayer. We want to see providers from all sectors delivering healthcare services. We have not the least wish to favour one type of provider over another. Indeed, as a result, and to ensure that the Secretary of State, Monitor and the Commissioning Board do not confer preferential treatment on any type or sector of provider, the Government have introduced amendments to Clauses 144, 59 and 20, inserting a new section, Section 130, into the National Health Service Act 2006.

We know very well that the voluntary sector plays a strong role in bringing the voices and experience of patients, service users and carers to the work of improving services, often reaching individuals who are excluded or who cannot access mainstream services. The voluntary sector brings advocacy and information to support individuals to exercise choice and control over the services that they access. These are major prizes, and we wish to capitalise on them. Opening up services to greater choice, for example, through “any qualified provider”—as was pointed out by the noble Baroness, Lady Finlay—allows for greater involvement by social enterprises or voluntary sector organisations. To a great extent, this is already happening.

Listening to noble Lords, I felt that there was a great deal of consensus around those points. There is a shared feeling across the House that charities have a key part to play in NHS provision, that the current VAT rules can act as a barrier and that this needs to be looked at very closely and urgently. I completely agree with that, and I would like to reassure the noble Lord, Lord Patel of Bradford, that we will ensure that this taxation issue continues to be considered urgently, as we develop work on a fairer playing field for delivering NHS services. In establishing Monitor’s new functions, the department and Monitor will continue to consider these issues and the priorities to be addressed.

The noble Baroness, Lady Armstrong of Hill Top, asked in particular what comfort there is in this Bill for the voluntary sector. She quite rightly mentioned the Future Forum in highlighting the work of the sector. The noble Baroness will be aware that the forum gave a very strong endorsement to the Bill’s creation of a bespoke provider regulator, Monitor, in order to oversee a level playing field. Such a commitment to a fair market was and remains a comfort to the voluntary sector. Of course, we acknowledge that more needs to be done, and that includes the ongoing work at the Treasury.

With those remarks, although I am sure that I have not completely satisfied the noble Lord, Lord Patel of Bradford, I hope that I have given noble Lords the sense that we are onside with this issue and shall be pursuing it with as much urgency as we can. I therefore hope that I have done enough to persuade the noble Lord to withdraw his amendment.

[Lord Patel of Bradford]

My Lords, I have listened carefully and with great interest to the many excellent contributions on this proposed amendment. I am grateful to the Minister for giving a very considered and what I believe to be a very sincere response by recognising the issues. Noble Lords have spoken eloquently about many of the issues: the huge numbers of services and people involved—it is absolutely the big society in action. Yet they also clearly talked about what goes to the heart of this Bill: the barriers that are there to stop the provision of equal services. My “unpopular” noble friend Lord Warner clearly outlined those barriers and I will not repeat them.

We have heard from my noble friends about the importance of the voluntary sector. The Minister clearly repeated the importance of the role of the charitable and voluntary sectors, and the fact that they work with some of the most vulnerable people in our society. I completely agree with the noble Baroness, Lady Barker, about the complexity of the situation. She raised the important issue of social enterprises and the potential exemptions and disbenefits there as well.

We are not asking to make a single-line solution to the problem; we are asking for clarity and transparency. This Government have clearly talked about transparency throughout, and it is so important for us to have that information. I listened to what the noble Earl said about them still discussing how the Treasury will go ahead and that they are in the process of taking urgent actions, but those urgent issues have been there for a long time. I suppose that I go back to the issue of my day job, when I am working with service users and local communities. When working with people with mental health problems and drug issues, nobody disagrees with me. Everybody says, “Yep—this is really important and urgent. We have got to look at it and we will. We will talk and we will make sure users are on the panel”, but we are still talking about it 20 years on. We need a document or something that focuses the mind. That is why the amendment seeks to ask the Secretary of State to give us the data.

I do not think that a year is problematic. I think it should be six months. Why do we not have these data? The whole premise of lots of the services we provide is that we need high-quality data to tell us what is missing and what is wrong. I am hoping that a report will be presented to give Members of the House an opportunity to reflect on that data and to look at what is going wrong, and where, because the big danger is that there will be a discussion between the charity sector and the Treasury, and that the Treasury will say, “This is what we can and cannot do—accept it”. It is important that the House and others outside look at the data and the transparency within that and make an informed decision. I will not keep the Committee much longer. It is such an important issue and, as I genuinely think that we should have a report presented to Parliament by the Secretary of State, I therefore wish to test the opinion of the Committee.

Health and Social Care Bill

Lord Patel of Bradford Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Lord Patel]

My Lords, my name is on the amendment and I am pleased to support it. Before I say what I wish to say, I declare an interest as an honorary fellow of the Royal College of Psychiatrists, an honour bestowed on me by the noble Baroness, Lady Hollins, when she was the president of that college, having been introduced in glowing terms to her by the noble Lord, Lord Alderdice—exaggerated glowing terms, I may add.

Noble Lords may wonder why I received that honour—and so do I—but I remember that at the time I was for several years chairman of the Clinical Standards Board for Scotland. It was during that time that I recognised that the provision of services for mental health was quite appalling compared to the services for physical health. It was through writing of standards for illnesses such as schizophrenia, to which the noble Baroness referred, that I discovered how appalling the situation was, not only in the environment where the care was delivered but in the care itself, and how that led not only to limitations in care but to limitations in resources for research and other end-producing standards.

It was of interest to read:

“Everything in my portfolio straddles the interface between health and care—mental health, social care, long-term conditions, cancer. Take for example mental health. The interdependencies between good mental health and good physical health are clear. Mental health sits at the point where health, social care and public health intersect. Delivering better outcomes in physical health will require mental health to be given parity of esteem. So that both mental and physical health problems get equal recognition in the commissioning and delivery of health and social care”.

These are not my words but the words of Mr Paul Burstow, the Minister of State for Health.

“Parity of esteem” is not defined in the document. However, it would be reasonable to expect that this would mean recognition of the equal importance of mental and physical health. Perhaps the Minister will help us with a definition so that we clearly understand what is meant by parity of esteem. You would expect this recognition to be evident in terms of access to mental health services; funding for services proportionate to the disease burden; and mental health being equally at the forefront of the minds of the new clinical commissioning groups and structures.

Sadly, however, this is not the case. For example, for a young person with a physical health problem such as diabetes, to which the noble Baroness referred, who is nearing an age where he is about to start receiving his care in an adult service setting, none of us would expect there to be any problem or difficulty with this move. However, consider a young person with a mental health problem about to make the transition to adult mental health services. Recent research indicates that as many as a third of all the young people who arguably needed continuing care did not make this transition. These young people fall into a gap that would not be acceptable in physical health care. Furthermore, even where a service is available, only 5 per cent of young people experience an ideal transition.

Next, consider the disease burden that is attributable to mental illness. Mental illness is a cause of suffering, economic loss and social problems. It accounts for over 15 per cent of the disease burden in developed countries—more than that caused by all cancers. In the UK, at least 16.5 million people experience mental illness. Despite this burden, a proportionate allocation of funding to mental health services often does not reflect that personal and economic scale. Nationally, some 12 per cent of the total NHS budget is allocated to mental health. While it is difficult to call for increased expenditure in the current economic climate, there is clearly a need.

There are clear benefits from mental health being regarded as the same as physical health. For example, poor mental health is associated with the increase of diseases such as cardiovascular disease, cancer and diabetes, while good mental health is known to be a protective factor. Poor physical health also increases the risk of people developing mental health problems.

The amendments are therefore appropriate. They will ensure that the Bill enshrines the principle of equality of physical and mental health in law so that commissioning bodies know their responsibility to commission high-quality and continuously improving mental health services, as they do for physical health. That commissioning bodies have such a responsibility can in no way be assumed from the present wording of the Bill. While it places a duty on the Secretary of State, the NHS Commissioning Board and the clinical commissioning groups to promote comprehensive health services in respect of both the physical and mental health of the people of England, the Bill makes no specific mention of mental illness with respect to their duty to the improvement in quality of services. It refers simply to the prevention, diagnosis or treatment of illness. I support these amendments and hope that other noble Lords will do the same.

[Lord Patel of Bradford]

My Lords, in speaking in support of these amendments I declare that I was formerly the chair of the Mental Health Act Commission. I have a long-standing interest in working to promote better mental health and in particular how we can best improve quality and outcomes in services. I echo what the noble Baroness, Lady Hollins, and the noble Lord, Lord Patel, have said and shall try to put a little bit more flesh on the bones.

It is clear to me from my work over the years in this area that we cannot and should not try to separate physical and mental illness. The separation of mind and body has been the focus of philosophical debate for many years but it is obvious to anyone who has at some time been unwell that physical problems have a profound impact on our mental well-being and that being unwell from a mental illness has profound impacts on our physical well-being. To quote the great American author and thinker, Henry David Thoreau:

“Good for the body is the work of the body, good for the soul the work of the soul, and good for either the work of the other”.

I could cite a great many examples that demonstrate that truth. As the noble Lord, Lord Patel, said, compared with the general population, people with depression are twice as likely to develop type 2 diabetes, three times more likely to have a stroke and five times more likely to have a myocardial infarction. Approximately 10 per cent of people have serious depression, but this rises among those with cerebrovascular disease, where rates of major depression are twofold. Among those with diabetes or cancer it rises to threefold, and among those with recurrent epilepsy it can be as high as a fivefold increase. In fact, living with a physical illness can adversely affect our relationships, causing isolation and anxiety, which can be just as debilitating as the physical illness itself.

Apart from the obvious common sense of these amendments, I am keen to see them passed because there is a need to bring these issues to the fore. Mental illness has for far too long been perceived as a Cinderella service lacking the serious attention it needs as part of a fully integrated health service. By creating parity between these twin aspects of our well-being and health, we can ensure that the improvements in quality that we all want to see are realised that much more effectively. In fact, I would go as far as to say that this is one of the single most effective things we could do to bring about these improvements.

By emphasising parity in health and mental illness for the Secretary of State, the clinical commissioning groups and the NHS Commissioning Board, we will see some very tangible benefits. For example, we could see a broadening of the Government’s health inequality agenda so that their indicators of disadvantage include mental illness and learning disability. The Royal College of Psychiatrists and the Disability Rights Commission have called for that. That would also help ensure that clinical commissioning groups seek improvements in health through the inclusion of mental illness in the annual health checks undertaken by GPs.

The implications for improvement in commissioning are profound and speak directly to the stated aims of the Bill: that is, continuous improvements in health and in the quality of services. While it is correct that the Bill calls on the NHS Commissioning Board and clinical commissioning groups to promote a comprehensive health service with,

“respect to both physical and mental health”,

there is still a need to be absolutely clear about the need for parity of esteem in physical and mental illness. This is not clear from the Bill as it stands. As the noble Lord, Lord Patel, said, it simply refers to,

“prevention, diagnosis or treatment of illness”.

That is likely to perpetuate the current imbalances which exist with respect to mental illness services and needs. For example, we currently spend approximately 12 per cent of health and social care expenditure on mental health services. The actual burden of disease is as high as 20 per cent when taking account of all disability adjusted life years. Bear in mind also that there will be only one secondary care specialist on the clinical commissioning group boards, who in all probability will be a representative from the physical health services. This amendment does not mean that there should also be a representative from mental health services but it will ensure that the clinical commissioning group is absolutely clear that it must commission equally high- quality and continuously improving mental health services.

By ending the unhelpful dualism between mental and physical health that has so characterised our services, we will see a holistic approach to health and healthcare. At the same time we will start to end the stigma that so many people have lived with and that has been the cause of so much misery and lost opportunities to help people be well. I am sure all noble Lords will agree that the stigma attached to mental illness has caused service users and their families a great deal of harm. I am pleased to say that public attitudes to this have been changing. In the 2011 Attitudes to Mental Illness survey, the percentage of people agreeing that,

“mental illness is an illness like any other”,

increased from 71 per cent in 1994 to 77 per cent this year. We should continue to support this positive trend in attitudes by emphasising the parity across mental and physical illness as these amendments seek to do.

The statistics show that this is not just a technical or even a semantic issue. The potential benefits are profound. In the same attitude survey, we learn that only 50 per cent of people would feel comfortable talking to their employer about mental illness and nearly a third said they would not be comfortable talking to a close family member or friend. The trends are moving in a positive direction compared to previous years but I am sure noble Lords will agree that we still need to do a great deal more to ensure that people are able to access help quickly and appropriately. Parity between physical and mental illness is one way in which we can strengthen that process.

I know that the Minister is a great supporter of issues related to mental health. I hope that he will support these vital amendments.