Health and Social Care Bill

Baroness Hollins Excerpts

Tuesday 11th October 2011 Lords Chamber

[Baroness Hollins]

My Lords, I worked in the NHS for 40 years, initially as a GP but for 30 years as a consultant clinical and academic psychiatrist, and of course I know that change and development are constantly needed to improve everyone’s health and well-being. I must admit, though, as a survivor of many top-down NHS reforms, that I favour incremental reform.

As a past president of the Royal College of Psychiatrists, I have been talking to the college and mental health charities regarding the Bill. I and they recognise many positive elements in it, in particular the proposed strengthening of clinical leadership and the focus on clinical outcomes and the interests of patients.

I want to make five points today. My first point is a question. Is there is a need for legislation at all? Is the Bill needed to enable the Government to press forward with their key reforms? I put this question to the chief executive of the NHS last night. If the Bill were dropped, what would the legislative gaps be? He replied that there would be a lack of certainty in the direction of travel. This Bill seems to have generated its own uncertainty among health professionals in the NHS.

Let me share the results of an electronic survey conducted over the weekend of members of the Royal College of Psychiatrists working in England. I am afraid that it is not good news. A staggering 84 per cent of nearly 2,000 respondents—20 per cent of eligible members—are asking for the Bill to be withdrawn. Eighty-five per cent think that the Bill would result in a more fragmented system of healthcare, and 86 per cent said that the Bill would not decrease bureaucracy. Successful reform requires the confidence and buy-in of those who work in the NHS.

My second point is about how this Bill can best address mental and physical health needs together in the NHS. We know that it is often the neediest who are denied access to psychiatric and medical services. It is true that sometimes mental health service users and people with learning disabilities may be more difficult to engage with due to their illness or their ability, and that can require extra time and skill. Our patients and the health professionals who work with them often face the problem of stigma, which other health professionals do not usually have to deal with.

What can the Government do about this? I suggest that one way would be for them to strengthen the presence of mental health in the Bill. I am preparing some amendments to help this to happen and I do hope that the Minister will see the wisdom of my suggestions. Specifying physical and mental illness in the Bill instead of just illness would enable the Government to stand firmly by their stated intention in the mental health strategy to ensure parity of esteem for mental and physical illness, and to recognise that there is no health without mental health.

Mind you, there is a long way to go to ensure parity of provision. Twenty per cent of the disease burden in the United Kingdom is attributed to mental health problems, compared with only 16 per cent for cardiovascular disease and 16 per cent for cancer. Unfortunately, only 12 per cent of the available resources are currently allocated to mental health, and sadly this inequity includes a lack of adequate investment in specialist services and research. No other health condition matches mental ill health in the combined extent of its prevalence, persistence and breadth of impact.

However, mental and physical illnesses are not quite as different as is sometimes supposed. It is unsurprising, given that the brain and the heart are in the same body, that depression and heart disease are so closely related. But people who are already patients of mental health or learning disability services suffer terribly from diagnostic overshadowing. In other words, if they have a diagnosis of depression, all their symptoms may be attributed to the depression. Their physical illnesses just do not get the same attention. Likewise, those with a primary diagnosis of heart disease, diabetes or stroke often fail to get adequate psychiatric attention. The mind/body split, which has been made far too concrete in the separation of service providers and in simplistic attempts to define tariffs, has not served patients well.

There are some statistics that highlight how, with more enlightened clinically-led services, we will perhaps be able to save lives and money. For example, more than 40 per cent of smokers have a mental health problem; and let me stress that smoking did not cause their problem. Paying greater attention to treating mental health problems might be a cost-effective way to improve many more people’s health and well-being.

My third point is about choice. Enhancing patient choice is not quite the right answer in mental health, unless by choice we mean involving service users in designing and managing their own care pathways. Indeed, choice is often rather a hollow concept in mental health services, with so many patients being treated against their will. Mental health services work closely with local GPs and other agencies in the community. Increasing choice for our patients could actually hamper access to an integrated and safe service, and to continuity of care—especially as these services are already about both health and social care, and the coterminosity of providers is important. Increasing the presence of the service user’s voice is much more important than choice, and the role of an independent HealthWatch could be key.

This brings me on to my fourth point, which is about introducing the new commissioning challenges at a time of austerity. I heard today from a senior psychiatrist about how the cuts are affecting direct patient care in his mental health trust, where 15 per cent of consultants are expected to leave in the next three years, and 10 per cent of community workers are to be lost in the next year.

For the first time, a health Bill has a very welcome clause about reducing health inequalities but there is doubt about whether the structures proposed will achieve this. The most significant concern emerging from mental health charities and the Academy of Medical Royal Colleges is that the Bill might actually increase health inequalities. I am sure that everyone in this House shares my wish to keep the NHS as a publicly funded service providing comprehensive care for the good of all the people. However, it is difficult to be optimistic about more positive outcomes being achieved through the new commissioning arrangements proposed for people with mental illness or people with learning disabilities.

Monitor’s role will include setting the price for services once commissioning boards have defined what will be bought. However, in mental health there are real difficulties in defining population and individual need. There is already good evidence to show that joint strategic needs assessments are failing to understand the needs of people with mental illness or those with learning disabilities. Given the wish of the Government to give more responsibility to clinicians, we need to make sure that new commissioning bureaucracy does not get in the way of letting individual clinicians create collaborative, innovative pathways with inbuilt continuity in partnership with patients. I am not talking here about Monitor's duty to maintain organisational continuity but instead about the continuity of individual care pathways, which is exactly what is required for so many patients with serious mental illness or for people with learning disabilities who also have associated physical or mental health problems. I can see neither how the new commissioners will be able to acquire such expertise in the near future nor how Monitor will be able to develop appropriate pricing expertise in complex mental health and social care in order to avoid horrendous planning blight for the foreseeable future. My experience is that planning blight has impeded progress after every top-down reform and that mental health and learning disability services have never been at the top of the priority list to sort out.

My fifth and final point is about public health and the link with wealth inequality. When I was a child and first talked about wanting to be a doctor, my father told me that the greatest improvements in health in the 20th century were due to the efforts of the Victorian engineers who reduced the incidence of cholera by better drains. However, an analogy with a utility company such as water would be simplistic in the 21st century. The 21st century equivalent of better drains is better public services above ground. Some of these will be health services, but health services are not fully responsible for preventing disease. A Government committed to rebalancing the current levels of wealth inequality that are bad for the whole population, not just disadvantaged groups, would achieve the greatest reduction in most chronic illnesses.

Most commentators talk of the NHS in terms of waiting lists but it is the management of chronic conditions that require continuity and flexibility that is more challenging. These are conditions that require people to stay in touch with specialist services for long periods of their lives. Such patients want a trusted local service, with in-patient beds for the times they get too ill to stay at home. This is not about shopping; it is about integrated personalised care.