NHS: Mental Health Services

Baroness Meacher Excerpts

Monday 8th October 2012 Lords Chamber

[Baroness Meacher]

My Lords, I congratulate the noble Lord, Lord Alderdice, for tabling this important debate; a debate, in my view, of national importance and of particular importance to the Government in their quest to take a million people off employment support allowance, or, in the future, universal credit figures within about 10 years. That is a major objective of this Government. We know that more than 40% of ESA claimants have mental health problems, the vast majority having depression or anxiety. That is nothing new. We also know that NICE recommends improving access to psychological therapies, and CBT most particularly. Not everyone likes the conclusions of NICE, or IAPT, but we have to take seriously the enormous amount of work that NICE does in looking at all the research available on a subject such as this and drawing its conclusions.

I do not share the views of the noble Lord, Lord Alderdice, that the style of therapy does not matter too much and that you can have bits here and there. This is a much more serious matter and people who practice these therapies tell me that these treatments, like other medical or pseudo-medical treatments, are potentially dangerous if they are not done really well. The quality of the therapist is absolutely vital and the methods and the types of therapy that they use. If we want to help people, rather than make them worse, it is no good using the wrong type of therapies, or short-term therapies, with the wrong kinds of people. We have to be very careful. It is essential that these IAPT services are of the best possible quality, which means, of course, using the best possible people. These services need to be available right across the country, so that GPs, wherever they are, can refer people for such help so that they do not lose their jobs—that, surely, has to be the first priority—or, if they have already lost their jobs, so that they can be prepared, as soon as possible, to get back into work and stop claiming benefits.

I shall leave my noble kinsman Lord Layard to talk about the national perspective. I shall talk about what is going on on the ground, as I am familiar with that. One problem is that the tendering process can result in services being provided by two or three different organisations. Far from just giving these services to the NHS, our experience is that they tend to be divided between different organisations. That may be all right but, over the years, health and social services have struggled to ensure that services provided across several organisations hang together and provide a good pathway of care for patients. It is very difficult on the ground; it sounds nice, but it does not work. The second best solution is to ensure that these different organisations work effectively together so that patients have a good pathway.

Competition rules may be being misinterpreted, but commissioners on the ground understand that these different organisations must use different IT systems, even though they are very happy to use the same one. The result is that these organisations do not communicate effectively with each other. That may be due to the limited understanding of commissioners. I do not think that the problem lies with competition, per se; I think it lies within the capacity of commissioners to operate competition in the best interests of patients and, to be perfectly frank, that simply is not happening.

Another issue is the tariff for IAPT services. The “any qualified provider” guidance for commissioners makes it clear that local commissioners should set their own tariffs. We know what happens if they do that. We know that the money supposedly put into IAPT psychological services is not ring-fenced and that local authorities are tempted to siphon it off into other things, and who can blame them? I do not blame them, but it means that we have to be very careful if we want a really good psychological service to deal with the unemployment problems of people with anxiety and depression. We cannot cut corners and a lot of tariffs are being set too low because of a lack of understanding.

The most serious problem, as I understand it, applies to steps 3 and 3 plus services. To treat effectively those with severe anxiety, severe obsessive-compulsive disorders and those with tricky, difficult and often multiple problems we need skilled therapists. That cannot be done by a low-cost therapist. Under AQP rules, a session of high-intensity therapy costs £40 to £50. High-intensity therapists themselves will cost more than that. There are also other costs such as administration, office costs and so on. However, when properly funded, we know from research that these services are highly cost effective; they get people back into work. The big question is why this is happening.

Even if trusts downgraded their intensive therapists from band 7 to band 6, which will inevitably mean losing their very best people—the noble Lord, Lord Alderdice, said, that they should not do that—and even if they made huge and probably unrealistic assumptions about productivity, organisations could not afford these services at steps 3 and 3 plus. My understanding is that steps 1 and 2, although challenging, will be deliverable. The whole benefit of the IAPT programme is that it is a stepped care programme. If someone is identified as needing step 2, and after a bit the therapist realises that that person has much deeper and more extensive problems than they originally presented with, they will need step 3 and if step 3 is not there, the value of step 2 will be lost. Such people will not get better and they will lose their jobs or not get back into work. That is the sort of concern felt at the bottom, where people are trying to deliver these services. I am not saying that they should all be delivered by the NHS. The NHS is having to renegotiate contracts and is having to cut the amount of money to deliver the same service, or something nearly as good. However, with IAPT it is not like that; it will all be tendered out, and change will be much more radical.

The view that I have had from others is that this consequence is more of a cock-up than a conspiracy. People are not trying to destroy this, but these AQP services will go live in November 2012 through to March 2013. The consequences of all these inadequate tariffs and problems on the ground, separating the different bits of the service across organisations, will become apparent during that six-month period and will get worse over time.

Before I finish I want to refer to a rather nice little piece of information, which supports my concerns. I happened to be at the Verulam School in St Albans talking about the House of Lords last Friday. The sixth formers were an impressive group of people. They were so concerned about mental health among young people—that is, themselves—that they undertook a survey of 1,800 young people in the St Albans area, which is not known for its deprivation. They really got at some of the problems and concluded:

“The value of mental health provision and the overwhelming need for it has become clear to us, as has the need for appropriate access and early support”.

They were very concerned about cuts to counselling support services for young people in St Albans. If you go along to east London you will find that things are even tougher, but it was interesting to find that result in a relatively well heeled part of the country.

I appeal to the Minister to do all that he can to rescue this inexpensive and highly cost-effective contribution to the Government’s goal to reduce unemployment. Will he try to ensure that IAPT is removed from the AQP system, if at all possible, even at this late stage? Will he try to secure the continuity of the central policy unit for IAPT? Those two things would transform everything. I have great trust in the Minister and look forward to hearing his comments.