Children and Young People: Mental Health Services
Baroness Hollins Excerpts(6 years, 10 months ago)
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Lord O'Shaughnessy
These are interconnected but separate issues. Anyone can suffer from mental health problems, including a high propensity of children with learning difficulties. A separate line of work led solely by the DfE is providing specific educational support for children with learning difficulties. The point of having specialist staff in all primary and secondary schools is to spot any child, whatever their vulnerability, and signpost them to services.
Baroness Hollins (CB)
My Lords, have the Government done any analysis of the numbers? My daughter is a child psychiatrist working particularly with younger children. She points out to me that there is little attention given to the needs of nought to two year-olds and their mental health in the Green Paper. We know that interventions are important in those early years. For the prevention of adverse childhood experiences and interventions after adverse childhood experiences, does the noble Lord consider it wise to ring-fence funds to support prevention and early intervention at that stage?
Lord O'Shaughnessy
The noble Baroness makes an excellent point about the importance of that age group. I will write to her giving the specifics of the support available to children and families with children of that age. A significant amount of funding is going into specialist perinatal and mental health services for mothers, which is a big part of the picture, but not the whole. Health visitors are being trained in mental health support. I will write to the noble Baroness with more details but I am sure there is more to be done.
Dental Care
Baroness Hollins Excerpts(7 years ago)
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Lord O'Shaughnessy
I recognise the benefits of fluoridation that the noble Lord has pointed out. There is no question about that. But we know that this is a very difficult and vexed issue locally—there are strong feelings either way. That is why the position was reached in the 2012 Act. The noble Lord’s idea of a discussion is a good one. I should point out that it is not a policy area on which I lead so I will have to speak to my colleague in the department, but if we can get that going and think about ways to encourage more action it would be a very clever thing to do.
Baroness Hollins (CB)
My Lords, I am sure that the Minister is aware that adults with learning disabilities are also at considerable risk of tooth decay, in part because of difficulties in maintaining their dental health. What measures are being taken to improve their dental health? I declare an interest here because I published a book on the subject. I am concerned too about excessive sugar consumption as a major cause of tooth decay. This is a risk for children and adults with learning disabilities. Will the Government consider introducing a ban on advertising high-sugar products on television before the watershed?
Lord O'Shaughnessy
The noble Baroness might send me her book so I can get her ideas on reaching adults with learning difficulties. Most adults with significant learning difficulties are likely to be on a range of benefits. That means that their dental care is free, if not for all, I suspect, then for some. She is absolutely right to point to sugar. We now have the sugar levy, which has had a really big impact. About 50% of drinks that would have been affected have been reformulated to either reduce or remove the application of that levy. That is a really good impact. On her point on advertising, we have very tough advertising rules in this country, including the banning of advertising of sweet drinks, sugary products and so on in children’s media. That is one of the reasons why we are seeing some hopeful signs on, for example, the number of extractions falling in primary care year on year.
NHS and Social Care: Winter Service Delivery
Baroness Hollins Excerpts(7 years ago)
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Baroness Hollins (CB)
My Lords, I remind the House that I am a family carer, retired psychiatrist and a past president of the British Medical Association, whose work I will refer to during my speech. There has been a lot of talk and publicity about the pressures on what are termed acute services. We have all seen the television images of trolleys and the problems in accident and emergency and so on; they make headlines and they are provoking debate—and I welcome today’s debate. One solution will indeed be a focus on the problem of delayed transfers of care back to the community. Without taking attention away from these important areas, I want to highlight similar concerns within mental health services, which seem to me to be as acute in nature as those described in general hospitals—although, in truth, they are not just confined to winter.
The British Medical Association’s bed occupancy report highlighted particular problems with high bed occupancy and delayed discharge in mental health settings. It identified the main reasons for delayed discharge as being a lack of suitable community services or facilities to support patients at home and a lack of available beds within local community or specialist facilities. Of particular relevance, given the ongoing review into the Mental Health Act, the BMA report noted an association between the reduction in mental health beds and the increase in the number of patients admitted following detention under the Mental Health Act, with the balance shifting towards a more acutely ill in-patient population. It seems sometimes that people have to be sectioned to get a service, even if perhaps that might not otherwise have happened.
In December 2017, the mental health charity Mind published its survey of over 1,000 people discharged from mental healthcare facilities and reported that patients found planning for their discharge was rushed and unsatisfactory, and that around half of patients experienced inadequate planning and support with housing and finances before discharge. If I had more time, I would give noble Lords some examples. Given these issues, it is surprising that the framework in the care Act for addressing delayed transfers of care seems to overlook patients with mental health conditions. One of the mechanisms to promote integration and co-operation between the social care sector and the NHS is the system of local authorities reimbursing the NHS for a delay in transferring care. This system is viewed as an incentive to improve joint working between health and social care. However, the provisions do not apply to mental health care, which is explicitly excluded from this framework. In fact, I understand that the only way a mental health patient may benefit from this framework is if they are unfortunate enough also to develop a physical illness that requires treatment under an acute medical consultant, but of course, ensuring adequate care planning for someone with a significant long-term social care need who also has an acute medical condition requires additional time and skill.
By no means do I think that fining local authorities is the sole mechanism for integrating social care and the NHS. The issue is rather more complex than such a blunt measure could resolve. However, that it is excluded from this framework suggests something about the way mental illness is prioritised compared with physical illness. If increased integration and co-operation between the health service and social care is what is needed for physical illness, why is it not also prioritised for mental illness? If the reimbursement provisions in the care Act are felt to drive integration and co-operation for those with physical illness, why not apply it to mental illness also?
While my amendment to the Health and Social Care Act 2012, on parity of esteem, may have helped to raise concerns and awareness of mental illness and parity of service provision, and outcomes are now regularly raised as critical goals in a modern health and social care system, this debate highlights yet another area where it is partly missing. Although I am very grateful to the noble Baroness who initiated the debate for referring to these issues, what worries me when we hear talk of winter pressures, black alerts in hospitals and crisis management is that it is in this environment that those with the most complex health and social care difficulties can be overlooked. Whether we expected such problems in advance or not, this is not an environment where we can deliver the best care for the most vulnerable people. Care services for vulnerable adults need to be part of a long-standing sustainable system. We cannot rush their discharge just because it happens to be winter. In fact, it is at this time when we should be most careful about discharge planning. Do we have more social workers, community mental health workers, community care placements and district nurses during the winter season in order to pick up the work from the overstretched general hospitals, or do we just settle for less robust discharges? If the latter, then clearly, those with complex mental and physical needs will suffer most—the very people who often find it hardest to make their voice heard.
A sustainable health and social care service cannot run at two different speeds: one for summer and one for winter. Careful, considered, joined-up care is needed all year round. This care does not suddenly appear when a winter crisis is identified.
NHS: Winter Funding
Baroness Hollins Excerpts(7 years ago)
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Lord O'Shaughnessy
I think that the trust has been clear that there are not going to be delays. If the noble Lord is talking about the story on the front page of the Times yesterday, the trust has subsequently been clear that it will not delay or curtail its treatments. We know that more nurses are required. That is why, as I am sure he will be pleased to know, there have been around 11,700 more nurses on wards in the last seven years.
Baroness Hollins (CB)
My Lords, I have heard from clinicians, including an on-call psychiatrist working over Christmas at St George’s Hospital in south London, about the difficulties experienced and the teamwork displayed to manage the exceptional strain and capacity problems hospitals face. Particular concern was expressed about the pressure to discharge patients quickly and the possible impact on people with learning disabilities or serious mental illness, especially given similar pressures in social care. What steps are being taken to prevent this, for example, by targeting flu vaccination to these vulnerable groups, but also to monitor the impact on them?
Lord O'Shaughnessy
The noble Baroness is right to pay tribute, as we should all do, to the incredible work that NHS and social care staff are doing during winter. Of course there is a need to discharge patients, but that should be only when it is clinically appropriate. If she has seen or heard of instances in which she believes that that is not the case I urge her to write to me with them. On how we deal with vulnerable groups, one example is clearly flu vaccination. I point out, and this is important, that not only were flu vaccinations offered for all NHS staff for free this year, with 60% uptake, but for the first time they were also offered to care home staff. That is a really important point about making sure we go to the community to prevent infection.
Social Care: Sleep-in Payments
Baroness Hollins Excerpts(7 years, 1 month ago)
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Baroness Hollins
To ask Her Majesty’s Government what steps they are taking to support (1) the care sector, and (2) those receiving care, in the light of the retrospective change in guidance on the application of the national minimum wage to sleep-in shifts for care workers.
Baroness Hollins (CB)
I beg leave to ask the Question standing in my name on the Order Paper, and I remind the House of my interests.
The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)
My Lords, we recognise that the historic liabilities associated with the national minimum wage for sleep-in shifts present a challenge to the financial position of many care providers. The Government have been working with representatives of the social care sector to understand how liabilities for back pay for sleep-in shifts impact on the provision of care for vulnerable people. We are exploring options to minimise any impact on individuals and the sector.
Baroness Hollins
The Minister will be aware of the considerable stress and anxiety faced by people with learning disabilities and their families about the likely loss of service providers. People with personal budgets who directly employ support staff fear being made bankrupt if they are found to owe arrears to them. We have been aware of this issue for some time now. Will the Government commit to funding these historical liabilities for sleep-in shifts and end the stress and anxiety which is now prevalent within this sector?
Lord O’Shaughnessy
We absolutely recognise the pressures that this has caused for providers of all kinds, whether they are large providers of social care or those with personal budgets in receipt of direct payments. I should point out that HMRC is working with local authorities where they are providing funding for direct care, so it is not just a discussion between individuals and HMRC. Local authorities are involved as well because they clearly need to look at the budgets they are providing to make sure they are adequate to pay for existing costs. We are looking at all the issues around historic liabilities, but I am afraid that I cannot give the noble Baroness the commitment she is asking for today.
Brexit: Mental Health Research Funding
Baroness Hollins Excerpts(7 years, 2 months ago)
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Lord O'Shaughnessy
In our future partnership paper we have set out that we want an ambitious agreement on science and innovation and that we will continue, albeit in a new form, to collaborate with the European Union on health research, including mental health research. On honouring the bids that were underwritten, I should point out that that applies not just to bids or projects that are taking place but to bids that have been submitted up until exit day, so there is a long lead time. It is also important to point out what the Government have been doing domestically. For example, the National Institute for Health Research has increased by over 50% the amount of funding that it puts into mental health research, so the Government have been going a long way in increasing the amount of funding in this area.
Baroness Hollins (CB)
My Lords, cancer research gets 25% of the UK’s annual research budget. The Minister mentioned that there has been an increase in the research money available for mental health but, as I understand it, mental illness gets only about 6% of the research budget. Why is that, and is there hope that that will be improved?
Lord O'Shaughnessy
In relation to the NIHR funding that I talked about and the specialist disease areas that receive funding, mental health is second only to cancer, so it is getting a great deal of funding. I could talk about the increase in the Medical Research Council’s budget and so on, but more funding is going in specifically to mental health research.
National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2017
Baroness Hollins Excerpts(7 years, 2 months ago)
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Baroness Hollins (CB)
My Lords, I am grateful to the noble Lord, Lord Hunt, for raising this issue. I am concerned about the additional barriers to care that may be faced by people with mental health conditions and learning disabilities. We know that such patients already face significant barriers to both mental and physical healthcare. For example, we know that people with psychosis already face significant barriers to both mental and physical healthcare. We know that people with psychosis face a mortality gap of 10-15 years, mainly from physical comorbidities. We also know that migration itself appears to increase the risk of psychosis, and the science behind this is developing rapidly.
It is not easy to divide, “immediately necessary” and “otherwise urgent” care, which is exempt, from routine care, which is chargeable. I speak from the standpoint of someone who has cared for patients with mental illness and with learning disabilities over many years as a psychiatrist, and also as a past president of the Royal College of Psychiatrists. The principle of early intervention to avoid a later crisis is widely recognised and promoted by the health service. Such intervention needs to occur very early. Identifying and intervening on low-level symptoms avoids escalation to more severe presentations that require intensive treatment and expensive admission to hospital. I am worried that the checks that have been put in the regulations will mean that patients, whether eligible or ineligible for free care, may wait longer and may need to be in crisis before they can access services. If this occurs, it will produce more suffering, increase risks and cost the health service more.
These costs do not feature in the Cost Recovery Impact Assessment, published by the Government in July. I am aware of examples of asylum seekers who arrive in this country with symptoms of post-traumatic stress disorder, and my concerns extend to the mental health of their children during periods of extreme uncertainty. Their mental health needs would not seem to meet the criteria for urgent care.
My other area of concern is the accuracy of decisions to deny care to a patient. The exemption for,
“immediately necessary, or otherwise urgent”,
treatment is a clinical one, as stated in the Government’s impact assessment. However, the British Medical Association, of which I am also a past president, has asked for clarification on the procedure when a person is unable to pay, including what safeguards are in place to prevent further or serious harm to themselves or the wider public as a result of them being denied treatment.
I am concerned that the process of administrative checks alongside a clinical test of urgency will be burdensome, costly and rushed. Once information is on a patient’s summary record, it may be difficult to change it or to amend errors. Such circumstances could lead to a failure to identify those entitled to free care. This may be even more complicated in patients who have impairment of capacity, communication difficulties or other mental health conditions. Challenging administrative errors and information on digital records in the health service can be difficult for all of us, let alone those with impaired capacity, communication and learning disabilities, or autism.
What safeguards are in place to prevent errors in requiring up-front payment? Without robust safeguards, those most in need of care may be those least able to prove they have a right to it. I would support the suspension of these regulations for further thought, but if this does not happen, can the Minister tell the House what are the arrangements for reporting the impact of these regulations on the mental and public health of the population who are at risk?
Baroness Redfern (Con)
My Lords, I refer to my entry in the register of interests. The regret Motion at first appears to imply that charging overseas visitors is something new. The requirement for the NHS to charge overseas visitors has been in place for 35 years—but, unfortunately, compliance and recovery rates have historically been extremely low.
I thank the NHS workforce for the fantastic job that they do; they are now treating levels of demand not seen before. Do noble Lords not think it only fair that any overseas visitor using our NHS should make a financial contribution, just as we all do when we are on holiday abroad and possibly want to access medical help?
It is important to emphasise that NHS England, NHS Improvement and the department have published guidance to support the embedding of the regulations, producing an average price list so as to better inform and enable patients to look at the up-front charges for anyone not eligible for free NHS care. Those people can then make informed choices about their care here or at home.
I am informed that, in order to protect the most vulnerable and to protect public health, the department remains committed to ensuring that vulnerable groups are always able to receive free care and that no patient will be denied urgent or immediate healthcare, regardless of their immigration status or ability to pay. This includes all maternity care in every setting, including diagnostic, and the treatment of infectious diseases.
Back in July, the department introduced new regulations to support improved cost recovery and make it fairer and more efficient for both the patient and the healthcare system. It saw recovery increase from £89 million to £360 million—all being transferred back into our front-line services.
Finally, with careful monitoring and ongoing assessments and with better use of existing data sources to improve efficiency, we will be able to see for ourselves the financial effectiveness and value for money through this process. These figures will be published in the new year.