NHS: Standards of Care and Commissioning

Baroness Hollins Excerpts

Thursday 31st March 2011 Lords Chamber

[Baroness Hollins]

My Lords, I, too, am somewhat daunted about speaking about my interests in this debate in such a short time, but I am grateful for the opportunity. I note that the Care Quality Commission has just published its second annual report. Encouragingly, it talked about safer services and an upward trend in the standards of healthcare.

Noble Lords would expect me, as a former president of the Royal College of Psychiatrists, to speak about people with mental illness and learning disabilities. I shall do that but I will focus on the physical health of people in that group and their access to acute hospital services. That relates to commissioning. Although I do not think that commissioning is the key to all the problems in the NHS, strong commissioning is important. At the moment, commissioning largely does not understand the needs of people with learning disabilities and mental illness, particularly when their needs are complex and they are seeking care in an acute hospital setting. I shall try to explain what I mean and will give two examples.

If we stop to think about maternity services—my noble friend Lord Patel may have a different view—we find that the most complex kind of maternity case is a mother with a severe mental illness. However, the current tariff does not cover the mental illness that that mother has and the obstetric department does not have to purchase mental health services to look after that mother. That is a real shame, as this is a good moment in a woman’s life to attend to her mental health needs and the mental health needs of her child. That is just one example.

The Bill sets out clearly the kind of duties that commissioners will have in the future and suggests that commissioners will need to seek advice, but what kind of advice is not clear. GPs will need to work closely with their clinical colleagues in different specialisms, particularly specialists in mental health, to ensure that their patients with mental illness get their ordinary, everyday healthcare needs supported and adequately met, and not just their specialist needs.

People who do not work in psychiatry often think that commissioning for mental illness or learning disabilities is about buying specialist services somewhere else and that it has nothing to do with the rest of the health system. That is just not true. There is no health without mental health and I am pleased that the Government’s policy on public health acknowledges that.

Because I have less than a minute, I shall turn only briefly to learning disability. Tom Clarke MP spoke in the other place yesterday about the NHS and public satisfaction. He spoke extremely eloquently and, since I do not have time to repeat all that he said, I encourage noble Lords to read Hansard. He talked about the long history of concern of Mencap and other bodies about the institutional discrimination that has been found in the NHS—not a culture of care but a culture of discrimination. The previous Secretary of State established an independent inquiry into healthcare for people with learning disabilities. It came up with some important recommendations, including recommendations for training all healthcare professionals. I would appreciate support from the Minister for such recommendations to be fully implemented when the new Bill comes in.

Health: Mental Health Strategy

Baroness Hollins Excerpts

Monday 14th February 2011 Lords Chamber

[Baroness Hollins]

My Lords, I am grateful to my noble friend Lady Murphy for securing this debate, particularly as it is the first debate on mental health since my introduction in November. I, too, declare an interest. Although I began my medical career as a general practitioner, I have worked for probably 35 years as a psychiatrist, particularly working with people with learning disabilities and complex mental health problems.

As a former president of the Royal College of Psychiatrists, I am quite accustomed to arguing the corner for mental health. I remember writing to Gordon Brown when he was Prime Minister suggesting that when he spoke about health, it would be a good idea to use the phrase “physical and mental health”. When the word “health” is used, people, including doctors, tend to think about surgery and surgical interventions, but not about mental health. Gordon Brown and the rest of the ministerial team then referred to physical and mental health for about six weeks. I wondered why it did not last any longer and came to the conclusion that it was because of the difficulty in trying to understand the complexity of mental health problems, plus the discrimination associated with mental illness and the fear and ignorance which go along with that.

There was a time when cancer was spoken about in hushed tones. No one had the language or the confidence to speak openly about it. In many ways, mental illness today is where cancer was all those years ago. My vision is of a time when mental illness will be spoken about more openly by politicians, the public and medical professionals; when everyone has a language and the confidence to express what needs to be said and what needs to be done; and when people with mental illness and learning disabilities will be more fully accepted and included in society. I am delighted that these are the objectives of this excellent new mental health strategy, No Health without Mental Health. I applaud its public health focus and the determination expressed within it for parity of esteem.

At the end of my presidency in 2008, the Royal College of Psychiatrists launched its manifesto, A Fair Deal for Mental Health. At the time, the campaign pointed out that only 12 per cent of NHS spending was on mental health, a share that did not accurately reflect the human and economic cost of mental illness. I therefore welcome the recognition in this strategy that mental health problems cost England £105 billion every year and that these costs are incurred across several government departments, including health, education and criminal justice. The challenge will be to address the imbalance between investment in physical health services and investment in mental health services at this time of financial constraint.

The failure of commissioners and managers to make provision for the overlap between mental and physical conditions leads to expensive and unnecessary investigations, such as for medically unexplained symptoms, and for missed opportunities to treat, for example, depression associated with heart disease. People who are depressed are much more likely to die from heart disease even when their depression has been effectively treated. This points to an interrelationship between physical and mental health which is rather overlooked. I always say to medical students, “Have you noticed that the brain and the heart are in the same body?”. There is plenty to research in this interrelationship, but the separation between physical and mental health has not allowed us to look at it properly.

I did not see much mention of research funding in the strategy document, although I may have missed it, but research will be a critical friend in the move towards better mental health services. Here is the rub: for every £1,000 of charity funding for cancer research, just £26 is available for mental health research. The stigma associated with mental illness has a negative impact on charitable giving for mental health research. Mental Health Research UK, the first mental health research charity, is struggling to establish itself and would benefit from proper funding so that it can begin to be a significant player in the research arena. Government sources such as the National Institute for Health Research need to start giving priority to mental health research in order to redress the inequity.

Finally, I should like to comment on the provision of appropriate treatments for all patients with mental health problems. I welcome the proposed increased investment in the Increasing Access to Psychological Therapies project, in particular the expansion to engage with harder-to-reach groups, but I am concerned that there are still no plans to extend talking therapies to people with learning disabilities who, again as far as I can see, receive no mention in the strategy documentation.

The nuts and bolts of how to provide effective treatments for people with complex mental health needs, such as those with learning disabilities, are often poorly understood. Face-to-face appointments are clearly an essential component of treatment, but the specialised supervision, consultation and multidisciplinary liaison that is needed behind the scenes is expensive, although crucial to enable success. Highly specialist teamwork is the only way of both managing risk and enabling patients with complex needs to access appropriate treatments and reach better mental health outcomes. The pathway from primary care treatments for people with common mental disorders to specialist mental health services for those with complex problems needs to be commissioned carefully.

I know that the noble Earl and the rest of the health team are determined to improve the quality of mental health outcomes, but I seek assurances that established complex needs services for people with severe mental illnesses, including services for those with learning disabilities with a dual diagnosis of mental illness, will not be cut to pay for the new public mental health programmes.

NHS: Global Health

Baroness Hollins Excerpts

Monday 20th December 2010 Lords Chamber

[Baroness Hollins]

My Lords, I, too, welcome the initiative of my noble friend Lord Crisp in calling for this debate.

As a former VSO volunteer myself in Nigeria many years ago—an experience that I consider to have had a major influence on my career and outlook—I am keen to give more opportunities for healthcare professionals today to gain a better understanding of global health issues. I should like to discuss attempts to develop greater awareness of global mental health issues, particularly in postgraduate psychiatric training by the Royal College of Psychiatrists, and I declare an interest as a former president of the college.

With the help of Professor Rachel Jenkins of King’s College, a scheme called the college volunteer programme was established about five years ago. We had wanted to set up a programme with VSO, as two other colleges had done, but this was difficult because VSO responds to requests for volunteers and it was not receiving requests for psychiatrists. In a way, that indicates the low priority given to, or low recognition of, mental health issues in many of the countries where VSO works. Therefore, we set up our own programme and gained agreement to the principle of out-of-programme placements abroad, fully approved for higher training. We put in place some safeguards, which included an in-country mentor providing supervision of all placements, with supplementary e-mail supervision from a UK-based consultant who had relevant overseas experience and who would have helped to prepare the volunteer in advance.

The intention was threefold, as I shall set out, although not in any particular order. The first was to provide a training experience in global mental health for UK trainees so that they would better understand the health perspectives and needs of migrant communities here in the UK. The second was to do that through meeting an identified need in the host country in a sustainable way. Often such needs were identified through our own college members and fellows who live and work in low and middle-income countries around the world. The third was to ensure that trainees would be equipped and motivated to be able to contribute to health services in low and middle-income countries in the future.

A number of mental health trusts have set up a specific link with a country, and I give as an example the trust where I have an honorary consultant contract—the South West London and St George’s Mental Health NHS Trust. While I was president of the Royal College of Psychiatrists, I talked to the chair of the mental health trust about ways in which he could help us to develop our volunteer programme. We thought that Ghana would be a good country with which to establish a relationship, partly because of its political stability but also because we were aware that the trust employed a number of Ghanaian staff, and the catchment population included many West Africans. The scheme at our trust was helped off the ground by a charity called Challenges Worldwide, which helped to set things up in Ghana. The scheme involved the trainee volunteer forgoing one month’s salary to cover the overheads involved in setting up the placement. The royal college fundraises to provide bursaries to support trainees’ travel costs. I shall quote two recent trainees who have each spent three months in Ghana. One said:

“This was for me the best professional training experience of my life … The support I received was excellent”.

The second said:

“My placement in Ghana was the most fascinating and perspective-changing experience in my career”.

Let us reflect on the fact that the NHS has for many years received the benefit of large numbers of health professionals from low and middle-income countries. Does the Minister agree that the value to the NHS of supporting training placements overseas far outweighs any short-term local costs? Also, can he confirm that all medical postgraduate curricula include core competences in global health issues, and will he comment on what more the professional regulatory bodies can do to ensure that enough appropriately supervised and integrated global health training placements are provided so that trainees have a realistic chance of acquiring some of those core competences?

Autism

Baroness Hollins Excerpts

Tuesday 7th December 2010 Lords Chamber

[Earl Howe]

My Lords, we cannot mandate to NICE what quality standards are produced. However, the case for developing a quality standard for autism will be considered as part of work to commission a comprehensive library of such standards from NICE in line with our plans in the White Paper. NICE is already developing clinical guidelines on diagnostic pathways for autism, including one for children and young people with autism. That is scheduled to be published in September next year. On training, I cannot really add much to what I have already said to the noble Lord, Lord Low, but it is very high on the agenda.

[Baroness Hollins]

My Lords, in respect of the training of medical students to be able to provide, in their future careers, adequate and reasonable adjustments for people with autism, what does the Minister think can be done to develop sufficiently existing equality and diversity training so that there will be adequate understanding and adequate adjustments will be made?

[Earl Howe]

The noble Baroness raises a very important point. We know from general practitioners that they feel an absence of knowledge and training in this area. We are talking to the royal colleges about this.