Health and Care Bill

Baroness McIntosh of Pickering Excerpts

Committee stage & Lords Hansard - Part 1
Tuesday 11th January 2022 Lords Chamber

[Baroness Hollins (CB)]

My Lords, I start by declaring my interests as a past president of the Royal College of Psychiatrists and a former consultant psychiatrist and clinical academic at St George’s, University of London. I thank Mencap and the Royal College of Psychiatrists in particular for the discussions I have had with them about this group of amendments.

I will not list all my amendments and those I am supporting in this group. I say to my noble friend that this is not just a spine-stiffener; it is a reminder, because we forget about mental health. We still forget to think about it and talk about it. One of the things I often do in my career is put my hand up and say, “By the way, what about mental health?” The noble Earl, Lord Howe, will remember the debate 10 years ago; I will come back to that.

The issues covered in these amendments are not new, because the World Health Organization definition of health is about a complete state of mental, physical and social well-being. It is not just about disease and infirmity. Noble Lords may not be aware—I heard this only recently—that a psychiatrist represented the United Kingdom at the first WHO meeting, which is probably one of the reasons why mental health was included at that stage.

These amendments would require the Secretary of State and all NHS organisations to prioritise physical, mental and social well-being. The idea is simply to replicate the parity of esteem duty as introduced in the Health and Social Care Act 2012. I re-read some of my speeches on that Bill, and I can see that I was persuaded to withdraw some amendments similar to those I am speaking to today. While a significant first step, that legislation ensured only that the Secretary of State for Health and Social Care would promote parity of esteem. What we have seen since then is a better understanding of the importance of mental health and mental health services, but there is still a gulf between the financing and delivery of these two equally important services, with physical health continuing to dominate. Of course, they should not really be separate, because there is no health without mental health. Integration is fundamental; we debated that at length in 2011-12 too.

The Royal College of Psychiatrists referred me to data published by NHS Digital last year. In March 2021, there were more than 400,000 referrals to mental health services—the highest ever recorded in a calendar month, and 36% higher than the beginning of the pandemic in March 2020. The pandemic has indeed shown us the importance of good mental health for the general population, including, of course, children and young people and health and care staff.

One of my amendments is on the duty of parity of esteem, and others insert “physical and mental” in multiple places to embed the fuller meaning of “health” in the Bill. I am grateful to noble Lords who are supporting this.

I want to focus on my Amendment 99, which places the duty to ensure parity of esteem at the integrated care system level. We cannot really leave it to chance; history tells us that this would lead to a suboptimal priority for mental health services. The duty that has been in place at national level for the Secretary of State has been so valuable that we can and should replicate it at a local level. Consider a recent survey by the Royal College of Psychiatrists in which two-thirds of respondents said that their ICS had not worked towards parity of esteem effectively. Fewer than one in 10 thought that their local area was effectively promoting parity of esteem.

But if a population health-based approach is core to ICSs’ planning and decision-making, I suggest that we need stronger legislative levers to support them to address mental health. Mental health is a key population need across the country. We cannot presently meet demand. No population health approach is complete without the inclusion of mental health, and yet we consistently see the imbalances in place. The new ICSs, bringing together commissioning and provision, could be a huge opportunity to get it right—or, certainly, a lot better—for mental health.

At present, there is no assurance in the Bill that mental health will be given equal precedence with physical health in integrated care systems or even by NHS England. My proposed duty for ICSs would help to ensure parity and repeat the success of the duty on the Secretary of State in the 2012 Act—not only that, but such a duty also increases focus at service level and would make sure that ICBs are looking closely at how they are providing for people at risk of or with a mental illness.

The trouble is that it is not easy to determine the best way to achieve this. As it stands, the Bill does not address parity at all. There are other similar amendments. Would putting this duty at the local level ensure that the next step in the battle for parity of esteem will be closer to the everyday experience of people who have struggled for far too long to access mental health services? Developing good integrated care cannot be just about meeting a person’s physical health. We must think more holistically about people’s psychological and social well-being, as mentioned by the noble Lord, Lord Howarth.

Turning to the amendments tabled by my noble friend Lord Stevens, which would strengthen transparency in mental health spending, he has a unique insight into the NHS and could not be better placed to advise on what improvements are needed in funding of our mental health services, particularly in accountability and transparency. The resourcing of mental healthcare is one—admittedly, only one—indicator of whether we have a chance of meeting the need and, we hope, preventing illness developing in the first place. We know that change is needed. There have been improvements in financing mechanisms. My noble friend mentioned the mental health investment standard. This feels important in light of the most recent spending review, in which, although there was a large funding injection for the NHS, mental health seems to have lost out again.

One wonders whether anyone remembered to ask the Treasury for additional funding for mental health. Having worked in mental health for so long, perhaps I may be forgiven for suspecting that it may have been forgotten once more. Last year’s uplift for mental health due to the pressures of Covid-19 was welcome but it was non-recurrent and those pressures have not gone away. Recent estimates from different charities that I have spoken to suggest that the overall share spent on mental health could go down in the coming year. We need these amendments to the Bill to make it clear that only when the Government and the NHS genuinely have mental health at the forefront of their efforts and are truly committed to parity of esteem, even in difficult circumstances, will we make good on the purpose of the NHS when it comes to the needs of people with mental illness in our society.

[Baroness McIntosh of Pickering (Con)]

My Lords, I am delighted to speak to this group of amendments, and I associate myself very closely with the remarks of the noble Lord, Lord Stevens of Birmingham, and the noble Baroness, Lady Hollins. I declare my interest in working for the Dispensing Doctors’ Association. I speak particularly to Amendment 263, in my name and that of the noble Baroness, Lady Tyler of Enfield, and Amendment 138, in my name and those of the noble Baronesses, Lady Tyler, Lady Watkins of Tavistock and Lady Bennett of Manor Castle.

All of us are touched by knowing or learning of those who suffer from mental health problems, and I express my disappointment as well to see that there has been no parity of esteem or parity of funding between physical and mental health. I urge my noble friend the Minister, when responding, to give a commitment, in the context of the Bill, to ensure that the role of the ICS and the other bodies under the Bill will make this happen for the first time in reality.

There are particular issues, as I have seen closely, primarily as an MP but also previously as a shadow Minister. In rural areas, particularly in isolation and where there are pockets of poverty, poor mental health is suffered particularly by those on low incomes and pensioners. The farming community, especially in times of hardship, has great difficulty in communicating anxiety and mental stress. Undoubtedly, the current pandemic has taken its toll, not just in terms of self-isolation quarantine but because many businesses, particularly small businesses, have collapsed, often through no fault of those who set them up.

The background to Amendments 138 and 263 is very closely associated with that of the others in this group. I thank and pay tribute to the excellent work of Anne Marie Morris, who moved these in the other place and is chair of the All-Party Group on Rural Health. I commend her work in this regard. As has been indicated, Governments of all persuasions over recent years have spoken regularly about their desire to achieve parity of esteem between mental and physical health, including in the NHS 10-year plan. However, for this to be meaningful, there must be a legal obligation in the Bill to that effect, supported by reporting mechanisms on inputs to the mental health system, in terms of money, people trained and training places, as well as outputs resulting, including the number of mental health appointments or services made available, uptake of those appointments and the outcomes—namely, the number of patients discharged from care.