Health and Social Care Bill

Baroness Hollins Excerpts

Wednesday 2nd November 2011 Lords Chamber

Moved by

[Baroness Hollins]

11: Clause 2, page 2, line 15, after “of” insert “physical and mental”

[Baroness Hollins]

My Lords, in moving this amendment I shall speak also to Amendments 105 and 180. I am pleased that they are supported by my noble friends Lord Patel and Lord Alderdice, and the noble Lord, Lord Patel of Bradford. The amendments concern the duty of the Secretary of State set out in Clause 2, in Clause 20 in respect of the National Health Service Commissioning Board, and in Clause 23 in respect of the responsibility of clinical commissioning groups. I speak as a psychiatrist and as a former president of the Royal College of Psychiatrists.

It is time for a paradigm shift in the way we think about the health of the people of this country. When the word “illness” is mentioned, I suspect that in most people’s minds there are images of physical illnesses such as heart disease, stroke, kidney failure and so on. The current wording in the Bill places a duty on the Secretary of State, the NHS Commissioning Board and clinical commissioning groups to promote comprehensive services in respect of both the physical and the mental health of the people of England. The Bill makes no specific mention of mental illness in respect of their duty as regards the improvement of the quality of services. I suggest that the word “illness” should be changed to “physical and mental illness” so that there can be no question about the Government’s commitment to ensure parity between services for physical illness and services for mental illness. The amendments would also be in keeping with the Government’s mental health strategy, No Health Without Mental Health, which states:

“We are clear that we expect parity of esteem between mental and physical health services”.

Noble Lords might think that there are some pros and cons to these amendments. I have discussed their purposes with mental health charities, service users, practising psychiatrists and other noble Lords. I believe that the pros strongly outweigh any possible cons, but I will deal with the suggested cons first. It has been suggested that there is no need to emphasise that illness encompasses both mental and physical aspects because of course it does; it is so obvious that emphasis is unnecessary. But the stigma associated with mental illness is still such that, on the whole, people do not self-disclose when they have a mental illness in the same way that they might talk about diabetes or cancer. I am sure that noble Lords can remember a time when cancer was a taboo subject, largely because of fear and ignorance. Unfortunately, a lot of the manifestations of mental health problems still evoke fear in the minds of the public. Until we start to name mental health and mental illness much more explicitly, I believe that we will allow mental illness to remain something which is not discussed in polite company, something that is kept out of sight and out of mind in spite of the fact that in each of our lifetimes, one in four of us will have mental health problems. Probably everyone in this House has someone in their family or among their friends or colleagues who is experiencing the symptoms of mental illness at this time.

It is not the same as including children or older people in the definition; nor to including a discrete group of conditions. Mental illness is relevant to every age and social group in the community. We all of us experience either good or less good mental health, just as we all experience good or less good physical health. Our physical health varies according to the presence of specific disorders, as does our mental health, and this applies just as much to children as it does to adults. Imagine a child with a complex neurological disorder who also has a mental illness. The child needs to be treated as a whole person with co-ordinated care by people who understand that the child’s mental and physical illnesses have equal priority.

The second possible con is that in labelling mental health in this way, specifically mentioning mental and physical illness, we might exacerbate the split between the two. Perhaps in 100 years’ time we will have adopted a sufficiently sophisticated understanding of health that defining health and illness as being about both physical and mental aspects will no longer be necessary. However, at this point in time, clarity is more important than any disadvantage that may come from naming both.

Another comment has been that mental illness is simply just another condition, similar to diabetes or stroke, perhaps, but this is not a 21st-century way of thinking about mental illness and mental health. The Government very helpfully earlier this year published their mental health strategy and called it No Health Without Mental Health. That is the point of these amendments: there is no health without mental health and there is no public health without mental health.

Given the scale of the changes the Bill introduces, the financial climate within which they will be implemented and the current underfunding of mental health services and care, I am keen to ensure that the Bill enshrines such a principle in law so that commissioning bodies can be under no illusion that they have an equal responsibility to commission high-quality and continuously improving mental health services as they have for services for physical illnesses. It would be extremely regrettable if the importance of mental health commissioning was overlooked because adequate reference to the parity that mental illness should enjoy with physical illness was omitted from the text of the Bill.

Mental health is part of the continuum of health, both for individuals and populations, and it cannot be thought about as if it was a discrete disorder or set of disorders. Medical science today is demonstrating what it should have taught us many generations ago: that physical and mental illnesses are inextricably linked. Do not misunderstand me: I am not suggesting that mental health problems are all down to biology and genetics; environment and relationships play an enormous part in supporting our mental health. This point was made very well on the “Today” programme yesterday, when a service user, a patient who had lived with schizophrenia, spoke about his experience of his illness. Professor Robin Murray from the Institute of Psychiatry, spoke about genetic imaging and other research into schizophrenia which so clearly shows that it is a brain illness, albeit strongly influenced by social and environmental factors.

The mind/body split has unhelpfully been set in concrete within the NHS, which uses different NHS trusts to treat mental and physical illnesses. This unfortunately fails to recognise the fact that depression, for example, is a very common co-morbid condition associated with diabetes, stroke and heart disease. It is not surprising, really, given that the brain is just one organ among many.

Mental illness in someone with a recognised physical illness is often overlooked, delaying that person’s physical recovery. As noble Lords will be aware, people who have severe mental illnesses are at an increased risk from a range of physical illnesses, as well as greater levels of obesity, and they have a shorter life expectancy. This is in part because, just as mental illness in those with physical illness is overlooked, so is physical illness overlooked in people with mental illness. We need to do more in all health services, including public health, to ensure that the connections between mental and physical illnesses are better understood; that service responses are co-ordinated; and that diagnostic overshadowing of one by the other is avoided.

We also need to recognise the part that education, training and research will play in achieving parity of esteem for mental and physical illness. Many factors contribute to the poor physical health of people with mental illness and, for many people with severe mental illness, social stigma, poverty, limited housing options and reduced social networks contribute to the problem, as do difficulties in accessing physical healthcare. I hope noble Lords will support me in inviting the Minister to agree to these small but significant additions to the Bill about which I feel so strongly. I beg to move.

--- Later in debate ---

With those comments, I hope that the noble Baroness, Lady Hollins, is more reassured and will feel able to withdraw her amendment.

[Baroness Hollins]

My Lords, I thank the noble Earl for his answer and indeed for the sustained interest and commitment that he has always shown to mental health services. I have been heartened by the enormous support across the House for my amendments and was impressed by the breadth of interest shown in mental illness.

There is wide recognition of the need to try to bring mental illness more into view, particularly perhaps to make it more explicit in the Bill. The indicators of better outcomes, about which the Minister spoke, are indeed welcome. We have heard how much they are needed. I hear every day of how mental health services are being disproportionately cut. We are still a long way from the kind of holistic service that we would all like to see. That is the difficulty and why I still feel quite strongly that we need to name mental and physical health. This may not be the right place in the Bill to do it, but I still think that when they hear the word “illness”, people think about physical illness. It may be defined but I do not think that it is what people hear. I have heard Ministers of Health and Secretaries of State speaking about health and illness over many years and nearly always when they do so we know that everybody is hearing “physical illness” and not hearing or thinking “mental illness”. We know that mental illness includes addiction and a wide range of different disorders and conditions.

I take note of what the noble and learned Lord, Lord Mackay of Clashfern, said and his question about where the amendment would best fit. I am willing to withdraw the amendment but I hope to hear more discussion and thought about how to show more explicitly in the Bill that there is a real intention in a 21st century Bill to have parity for mental and physical illness. In 100 years’ time somebody could be standing here arguing to take away the words “mental illness” because they are no longer needed, but we are such a long way from being able to do that. I am not arguing that mental illness is just a medical condition—not at all. It is a condition, as the noble Lord, Lord Alderdice, reminded us, which affects the very essence of our being. It requires integrated services and integrated approaches; it requires medical attention. But it also requires an awareness of the social recovery models of support and help. I will bring back the amendment at the next stage. I beg leave to withdraw the amendment.

Amendment 11 withdrawn.