Health: Parity of Esteem

Baroness Tyler of Enfield Excerpts

Monday 28th November 2016 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I congratulate my noble friend Lord Alderdice on securing tonight’s debate, which provides a timely opportunity to consider one of the most fundamental issues in healthcare today. Efforts to achieve equal value of physical and mental health span many decades. The Royal Commission of 1957, the year of my birth, noted, not quite in today’s language, that:

“Most people are coming to regard mental illness and disability in much the same way as physical illness and disability”.

That was almost 60 years ago.

In recent times there has been a welcome shift in public attitudes towards mental health and a growing commitment among communities, workplaces and schools, and within government, to change the way we think about this issue. As we know, there have been a raft of commissions and taskforces as well as Future in Mind, looking at young people’s mental health, and of course the recent Five-Year Forward View for Mental Health. They have provided many important recommendations on how we can achieve genuine parity of esteem. They have all stressed, as has been stressed tonight, the inextricable link between mental and physical health. What does that actually mean? To help define this, I looked back at the All-Party Parliamentary Group’s very good report last year on parity of esteem. It said:

“What this would mean in practice is that taking a holistic view of an individual’s health (seeing the interdependencies between both their physical and mental health needs) would be the norm”.

Having listened carefully to my noble friend Lord Alderdice, I would add “health and well-being”.

The fundamental question for us is why it has been so difficult to achieve real and sustained progress. I did a quick survey of the scene, and many aspects I did not find very reassuring. As Michael Marmot so powerfully reminded us in his recent book The Health Gap: The Challenge of an Unequal World, people with mental ill health have a life expectancy between 10 and 20 years shorter than people with no mental illness. I am sure we all find that shocking.

Only a quarter of those with mental illness such as depression are receiving treatment, a figure that contrasts with 78% of those with heart disease and 91% of those with high blood pressure. A recent CQC report noted that, when facing a crisis, a shocking 32% of people do not know who to contact out of hours. Indeed, 24% of those who did know said they did not receive the care they needed.

It is not all doom and gloom—there has been some progress. Thanks to the persistence particularly of Liberal Democrats in the coalition Government, the first ever mental health waiting time standards were introduced. This was a real achievement and helped to bring mental health services into line with other NHS services, such as cancer and A&E waiting times. It was a tangible step on the journey towards parity of esteem. However, as the Mental Health Taskforce report earlier this year noted, for first appointments and for the right follow-on support, waiting times are still “unacceptably long”. Only a couple weeks ago, the Education Policy Institute’s report Time to Deliver found that only 18% of areas were meeting the four-week waiting times for routine cases and only 14% were meeting one-week waiting times for urgent cases. The noble Lord, Lord Lansley, drew attention to this lack of progress, and I very much look forward to hearing what the Minister has to say.

A number of factors underpin that lack of progress, and I want to focus first on the problems of funding, both disparity and historical underfunding. To their credit, the Government committed £1.25 billion to children and young people’s mental health over the next five years, which is £250 million a year. Despite that commendable promise, only £143 million was released in the first year and of that, only £75 million was actually distributed to clinical commissioning groups. Even less got to the front line.

As we have already heard, last year, across the board, 40% of NHS mental health providers had their funding reduced, despite NHS England instructing commissioners to increase it. This raises serious questions as to whether funding is reaching the areas where it is most needed, and it highlights the damaging impact of the Government’s refusal to ring-fence mental health funding. I know Jeremy Hunt said that he does not have the power to do that, but frankly, Governments, if they are so minded, can do something about it if they do not have the powers.

It is the same story with the £1 billion announced last year for mental health, much of which does not come on stream until the end of this Parliament. One could be forgiven for assuming that in last week’s Autumn Statement, the Chancellor would have offered a lifeline to mental health services, as well as other areas of health and social care. Instead, the Government found £240 million for the expansion of grammar schools, but not a penny for the NHS.

On a more positive note, the introduction of the five-year forward view included dashboards, an initiative welcomed by the Royal College of Psychiatrists. I, too, welcome them as representing a viable solution to ensuring better accountability and transparency from clinical commissioning groups. Obliging CCGs to publish facts and figures on their spend on mental health and the services they deliver will go some way to addressing the funding disparity, and stop money intended for mental health being siphoned off elsewhere. What is being done to publicise and promote the CCG dashboards, and how will people be able to compare the performance of their local CCG with others in other parts of the country?

Funding impacts on other factors which are also preventing parity of esteem. The mental health sector, in particular, is suffering from recruitment and staff morale problems. As noted in the report of the noble Lord, Lord Crisp, on acute adult psychiatric care, Old Problems, New Solutions, these problems are in part due to disproportionate financial cuts. The same report found an 8% decrease in the number of mental health nurses between 2010 and 2014, while there was a 1% increase in physical healthcare nurses over that period. Given that NHS England estimates that implementing access and waiting time standards will require a 7% increase in the number of mental health nurses by 2020, how do the Government expect to achieve that standard without staffing levels rising?

It is not for lack of ideas, recommendations or reports that progress on parity has been unsatisfactory—nor is it, as many other noble Lords have said, solely about money. There are other, non-financial issues, including cultural issues, and that provides the starting point for the Values-Based Child and Adolescent Mental Health System Commission, which I had the privilege of chairing. Its report, published on 7 November, explores how different values drive deep-seated culture, attitudes, decision-making, practice and behaviour—the invisible drivers, if you like—which can either inhibit or promote a truly system-wide approach to redesigning and transforming services. The report’s 10 recommendations were all about how a more explicitly values-based approach with a shared language could really improve the mental health and well-being of children by focusing single-mindedly on what really matters to them. That report, and the recent report Time to Deliver, by the Education Policy Institute, chaired by my right honourable friend Norman Lamb, had a number of important recommendations. In particular, it proposed that the Prime Minister should announce a national challenge on children’s mental health. Can the Minister indicate how the Prime Minister intends to respond to that recommendation?

In conclusion, we should aim to achieve a healthcare system in which parity of esteem means that mental healthcare is not only as good as physical healthcare but is delivered, as the recent King’s Fund report recommends, as part of an integrated approach to health and well-being, as my noble friend Lord Alderdice so powerfully reminded us this evening.

Disability: Premature Deaths

Baroness Tyler of Enfield Excerpts

Monday 17th October 2016 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I congratulate the noble Baroness, Lady Hollins, on securing this debate and on being such a tireless champion for the rights of people with learning disabilities to receive the same access to and quality of healthcare that the rest of the population takes for granted. I also congratulate the noble Baroness, Lady Fall, on her excellent maiden speech. I am sure we will be hearing much more from her. I associate myself with the fulsome tributes paid, rightly and movingly, to our late colleague Lord Rix.

As we have already heard from the noble Baroness, Lady Hollins, the 2013 Confidential Inquiry into Premature Deaths of People with Learning Disabilities was set up to investigate the avoidable or premature deaths of people with learning disabilities through a series of retrospective reviews. I hope noble Lords will forgive me for repeating several statistics. I know that those in the Chamber tonight will be familiar with them, because they are passionately concerned with this issue, but the statistics bear repetition because, in a way, they say it all. We have already heard, from the noble Baroness, Lady Rawlings, the shocking statistics that men with learning disabilities die, on average, 13 years sooner than men in the general public and women with learning disabilities die 20 years sooner. Overall, 22% of those people were under 50 when they died. These are not just dry statistics, they are deeply shocking and nothing short of a national disgrace. Perhaps the most shocking statistic of all is the confidential inquiry’s finding that 37% of deaths were potentially avoidable if good quality healthcare had been provided.

As so often happens when you start to delve into statistics, the situation across the country is very variable. An independent review of deaths of people with a learning disability or mental health problem in contact with Southern Health NHS Foundation Trust between 2011 and 2015, commissioned by NHS England, found a number of serious failings. These included the trust having no effective way of reporting, investigating and learning from deaths. It also found that, while 30% of deaths in adult mental health services were investigated, only 1% of those of people with learning disabilities were investigated. What are we to make of the statement made by the former chief executive of Southern Health? She said:

“We believe that Southern Health’s rate of investigations into deaths is in line with that of similar NHS organisations”.

I leave noble Lords to draw their own conclusions from that.

As we have already heard from the confidential inquiry, one of the 18 key recommendations was the establishment of a national learning disability mortality review. A key part of the review programme, commissioned again by NHS England, is to support local areas to review the deaths of people with learning disabilities and take forward the lessons learned to improve services. I am sure we all think that is what should happen. So far, so good. However, as has already been referred to by the noble Baroness, Lady Hollins, participation in the programme is not mandatory, so, unlike the child death review process, and, indeed, many other inquiries, agencies can choose whether or not to contribute to the review of deaths of people with learning disabilities. In the current financial climate, I guess it is understandable that many organisations choose to do only what they have to. In my view, giving this issue mandatory status would undoubtedly raise the profile of the work and show that the lives and deaths of people with learning disabilities are valued. That is the crux of what we are talking about tonight.

I know there are also serious concerns over the sustainability of local reviews of deaths of people with learning disabilities once the review programme ends. Therefore, in responding, will the Minister update the House on the review’s overall progress? Does she agree that if we really want to stop people with learning disabilities dying prematurely because they are not getting good-quality healthcare, the mortality review should have a mandatory rather than an optional status?

Finally, on a related issue of sustainability, the Public Health England Learning Disabilities Observatory, set up in the wake of the independent inquiry chaired by Sir Jonathan Michael, was established to keep watch over the health of people with learning disabilities and the healthcare they receive. It also provides data, information and advice to commissioners, families and people with learning disabilities about good practice and local performance in achieving improvement. Current funding for the observatory is guaranteed only until March 2017. Therefore, what assurances can the Minister give that funding will continue to be available for the vital work that the observatory is carrying out?