Mental Health

John Pugh Excerpts

Thursday 14th June 2012 Commons Chamber

[Nicky Morgan]

I entirely agree with the hon. Gentleman. The Centre for Mental Health has shown that for a person who has a physical and a mental health condition, the costs of treatment are increased by 45%. Those are additional costs around mental health problems, which are often untreated initially and then have to be treated at a later stage, so the hon. Gentleman is absolutely right.

According to the Centre for Mental Health, only a quarter of people with mental health conditions—children as well as adults—receive any treatment. I have no reason to doubt that statistic, and I find it shocking that three quarters of people with mental health conditions are not being treated. We should ask ourselves why that is.

Recent figures have shown that depression alone is costing the economy £10 billion a year. As we all know, we do not have a lot of money to spend, so we should be working as hard as we can on preventive measures. One in every eight pounds spent on dealing with long-term conditions is linked to poor mental health, which equates to between £8 billion and £13 billion of NHS spending each year.

I welcome the Health and Social Care Act 2012. I hope that today’s debate will be conducted on pretty non-partisan terms, but I realise that that may strike Opposition Members as a controversial comment. I welcome the opportunities that the Act offers for the commissioning of mental health services. I spoke in the Third Reading debate, and I especially welcomed the Government’s acceptance of an amendment tabled in the other place to ensure parity between physical and mental health. Although those are only words in a Bill, they are very important words, and they send a very clear signal not only to sufferers from mental health conditions and their families, but to those working in the NHS. I hope that, in his annual mandate to the national commissioning board, the Secretary of State will insist that the board prioritise mental health.

How are we to achieve parity between physical and mental health conditions? The question is about money, certainly, but it is also about awareness. Confessing to having a mental health condition carries far too much stigma. That is part of the reason for our wish to hold a debate on the Floor of the House. If we do not start to talk about mental health in this place, and encourage others to talk about it, how can we expect to de-stigmatise mental health conditions and enable people to confront their problems?

I find it interesting that, when I was preparing for the debate, a few people who had initially said to me “Yes, go ahead, mention my name” came back after thinking about it for a couple of days and said “Actually, I would rather you didn’t, because I have not told my employer,” or “I have not told all my friends and my family.” It is clear that mental health conditions still carry a considerable stigma. Admitting to having been sectioned is traumatic, especially when the information appears on Criminal Records Bureau checks connected with job applications.

I welcome the work of Time to Change, which has been funded partly by the Department of Health as well as by Comic Relief. I also welcome the Sunday Express campaign on mental health. However, the de-stigmatisation of mental health conditions is down to all of us, and it is especially important for those of us who are employers not to discriminate against people who may be working for us and who tell us that they have a mental health condition. I hope that today’s debate will constitute another firm step on the path to ensuring that mental health conditions are de-stigmatised, because I think that without that de-stigmatisation, successful treatment will be very hard for a person to achieve.

We asked for today’s debate to be kept deliberately general, so that Members in all parts of the House could raise many different issues on behalf of their constituents and, perhaps, themselves or their families as well as looking at the mental health policy landscape. Mental ill health is no respecter of age or background. It can strike anyone, often very unexpectedly. That includes people in senior positions such as Members of Parliament, company directors and school governors. I am sure that my hon. Friend the Member for Croydon Central (Gavin Barwell) will refer to the private Member’s Bill that he will be presenting, which would end discrimination against people in such positions who have mental health conditions.

I expect that during today’s debate we shall hear about new mums with post-natal depression. For them, a time of life that should be one of the happiest is often one of the most difficult. I welcome the recent Government announcement that health visitors will be properly trained to recognise signs of post-natal depression, which I think was long overdue. I expect that we shall also hear about veterans from our armed forces who suffer from mental health conditions, and about older people who suffer from dementia. Particular issues affect our black and ethnic minority communities, as well as those who find themselves in the criminal justice system. I am sure that we shall hear from the Minister abut the Government’s widely welcomed framework document “No health without mental health”, which was published last year. We now await the detailed implementation plan on which the Department of Health is working alongside leading mental health charities.

I want to talk, very briefly—I have noted Mr Speaker’s strictures about time limits—about three specific matters: listening to patients, integrated care, and the wider mental health well-being landscape. We made it clear during the passage of the Health and Social Care Act that one of the developments that we wanted to see, as a Government, was “No decision about me without me.” That means patients having a voice in their care. It seems to me from my discussions with those in the mental health system who have been sufferers that once the initial crisis has been dealt with, they tend to want choice and involvement in their treatment. They are facing a lifetime condition. They will have to self-medicate, look after themselves and identify the point at which they may be deteriorating or potentially reaching crisis point for years and years to come. They want a voice. They want to be heard by the health care professionals, and I think that it is up to us as a Government to help them to achieve that.

[John Pugh (Southport) (LD)]

The hon. Lady has just said that people who suffer from mental health problems have a lifelong condition. I think that many people have an occasional mental health problem.

[Nicky Morgan]

I am not sure that I entirely agree with the hon. Gentleman. I agree with him that people often enter the system at a time of crisis and experience a single episode, but others who experience episodes will get better. For years they may have no problems at all. The hon. Gentleman shakes his head, but I can tell him on the basis of the experience of constituents and family members that it is possible to go in and out of the system. One of the hardest things for people to accept when they are diagnosed with a mental health condition is that they will be on drugs for years and years. That is often difficult for people to admit, particularly when they are striking up a new relationship or working for a new employer. I think that that is why people want to have a voice in the way in which they are treated.

According to Mind, people are three times as likely to be satisfied with their treatment if they are presented with a choice of treatments, and failure to stay on medication is the main cause of relapses, when people often have to re-enter the system at a time of crisis. There is a need to work with and trust health professionals. According to a recent study by the university of Kent,

“Low levels of trust between mental health patients and professionals can lead to poor communication which generates negative outcomes for patients, including a further undermining of trust”,

and

“trust can play a significant role in facilitating service users’ initial and ongoing engagement with services, the openness of their communication, and the level of co-operation with, and outcomes from, treatment or medication.”

In 2009, a mental heath in-patient survey by the Care Quality Commission revealed that in some mental health trusts as few as 40% of people diagnosed with schizophrenia felt that they were involved as much as they wanted to be in decisions about their care and treatment. I am no health professional—I hope that some Members who are health professionals will speak later this afternoon—but what people have said to me suggests that medication is not always the answer, at least in the long term. Research by Platform 51 has found that a quarter of women have been on anti-depressants for 10 years or more, that half of women on anti-depressants were not offered alternatives at the time of prescription, and that a quarter of women on antidepressants have waited a year or more for a review of their medication

I welcome the Government’s investment of £400 million in treatments under the improving access to psychological therapies programme. I should add, to be fair, that that builds on announcements made by the last Government. I also commend the report by the Centre for Social Justice on talking therapies, which calls for a broadening of therapies. Every patient is different, and patients will respond differently to different medications and therapies. Mental health patients must have real choice, and I think that Any Qualified Provider and Payment by Results must be extended to them in the way in which they are being extended to patients with physical health conditions. We must also ensure that patients’ voices are heard within the management structures of both clinical commissioning groups and health and wellbeing boards, whose job it is to hold services to account for the care that they are giving.

I expect that Members will refer to integrated care: the need for all services to work together. Poor mental health has an impact on every area of Government policy: health care, benefits, housing and debt, social exclusion, business and employment, criminal justice and education, to name but a few. One person with a mental health condition may need help from many different agencies, but too often care is not joined up, and each agency deals with its own bit and passes the person on. Sometimes there is no follow-up, and the person is lost in the system.

In a 2011 survey, 45% of people contacted by Mind said that they had been given eight or more assessments by different agencies in a single year. YoungMinds, which campaigns on behalf of children and young people with mental health conditions, has called for one worker to be allotted to each child needing support for a mental health condition, so that children can avoid multiple assessments and need not re-tell their story each time they see a new person in the system. However, there must be a clear care pathway, whatever the point at which access is gained to the mental health system.

The other thing patients are calling for is the ability to self-refer. We need to do all we can to prevent people from reaching crisis point, and often it is patients themselves who are best able to tell when they are about to reach that point. My West Leicestershire clinical commissioning group is developing an acute care pathway in partnership with Leicestershire Partnership NHS Trust. It plans to replace the many and varied access routes to secondary care and mental health services with a single access point, in order to provide speedy access at times of greatest need. That move has come out of both patient and GP feedback.

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[Andy Burnham (Leigh) (Lab)]

I begin by giving my apologies to the hon. Member for Loughborough (Nicky Morgan) for missing the beginning of her speech, and by congratulating the Minister on his excellent and thoughtful speech, to which I can hopefully add something.

I have high hopes for the debate. I hope it will help us to confront a major paradox: how can a subject that is so central to the big public policy challenges we face as a country—the challenges are not just of public health provision, but of worklessness, benefits, the criminal justice system and addiction—still exist on the fringes of our national debate, getting so little airtime and attention? As other hon. Members have acknowledged, the House, sadly, rarely applies itself to mental health. Perhaps that reflects our national stiff-upper-lip tendency not to talk openly about mental health, which in turn might help to explain why our public services are designed for the 20th century rather than the 21st.

[John Pugh]

The right hon. Gentleman seems to be forgetting that we had appreciable mental health legislation in the last Parliament—the Mental Health Act 2007.

[Andy Burnham]

I am proud of the improvements we made in the last Parliament, but I did not come here today to say that everything the previous Government did was right and wonderful. I will talk a little about those improvements, but given my failure to sing about Labour achievements, I am grateful to the hon. Gentleman for doing so.

We are reticent to talk about mental health as much as we should. There is a complacency in the public debate—that is not to make a political point, because it involves hon. Members on both sides of the House. The complacency goes throughout the civil service and the Government. To reflect on my time in government—not just in the Department of Health, but in the Treasury and the Home Office—it is remarkable how few submissions or meetings I had relating to mental health, given that it underlies the spending of hundreds of millions of pounds of public money. Indeed, £105 billion is the estimated cost of the full burden of mental health to this country.

That complacency is not shared by everybody and I congratulate the hon. Lady on introducing this debate. We have heard two unbelievably powerful speeches, from my hon. Friend the Member for North Durham (Mr Jones) and the hon. Member for Broxbourne (Mr Walker), to which I will turn at the end of my remarks. My hon. Friend the Member for Hackney North and Stoke Newington (Ms Abbott), who leads on these matters for the shadow health team, has rightly pointed out how mental health lies under the whole public health challenge. We will soon introduce Labour’s public health review.

We are beginning to wake up from our complacency. I am leading the debate for the Opposition to show that that comes from the top. We see the mental health challenge as central to health policy. Indeed, I made a point of making my first speech on returning as shadow Health Secretary on the subject of rethinking mental health in the 21st century at the Centre for Social Justice.

I must be honest: I shared the complacency about the mental health debate, or perhaps did not give it enough attention, but two things changed that when I was a Health Minister. First, I spent a day work-shadowing an assertive outreach team in Easington. I will never forget what one of the team told me about the early ’90s, when the mines closed and GP referrals for support were piling up on clinic desks, but there simply was no support to offer people. She said that that lay behind the social collapse in those mining communities. People facing difficult times were given no help.

A second thing made me think differently. When I became Health Secretary in June 2009, I inherited Lord Bradley’s report into mental health problems and learning disabilities in the criminal justice system. I will never forget sitting in my office at Richmond house reading that about 70% of young people in the criminal justice system have an undiagnosed or untreated mental health problem. If that is not truly shocking to every Member and does not make us do something, frankly nothing will. That was the moment that changed how I thought, and I have tried to follow it through ever since.

I mentioned that we had a public service designed for the 20th century, rather than the 21st century, and I want to illustrate that point with reference to my own constituency. The world that gave birth to the NHS was a very different place. When the NHS was set up, Leigh, like Easington, was a physically dangerous place to live and work in. Working underground exposed people to coal dust, explosions and accidents, and people had no choice but to lock arms, look out for each other and face the dangers together—that is how it was—and that spirit of solidarity was carried over into the streets above.

Like many places in this country, then, Leigh in the ’50s was a physically dangerous place but emotionally secure, because people pulled together. In the 21st century, however, that has completely reversed. We now live in a physically safe society—our work does not generally expose us to dangers—but it is emotionally far less secure than it was for most of the last century. The 21st century has changed the modern condition. We are all living longer, more stressful and isolated lives, and have to learn to cope with huge and constant change. Twentieth-century living demands levels of emotional and mental resilience that our parents and grandparents never needed, yet the NHS does not reflect that new reality; essentially, it remains a post-war production-line model focused on episodic physical care—the stroke, the hip replacement, the cataract—rather than the whole person. That is the issue to confront.

The demands of this society and the ageing society require a change in how we provide health and social care. We need a whole-person approach that combines not only the physical but the mental and social, if we are to give people the quality of life that we desire for our own families. That one in four people will experience a serious mental health problem makes this an issue for all families and people in the country. It also means that mental health must move from the margins to the centre of the NHS.

I shall say a couple of things about that necessary culture change. How can it be that an issue that causes so much suffering and costs our society so much still accounts for only a fraction of the NHS budget? It cannot be right. We also have to consider the separateness of mental health within the NHS. This has deep social roots—the asylum, the separate place where people with mental health problems were treated, the accompanying stigma and suspicion about what went on behind those four walls. Essentially, we still have the same system in the NHS, with separate organisations—mental health trusts—providing services on separate premises. That maintains the sense of a divide between the two systems and raises a huge health inequalities issue.

The wonderful briefing that Mind, Rethink and others have prepared for this debate contains this startling statistic: on average, people with severe mental health problems die 20 years earlier than those without. What an unbelievable statistic! Why is that? It is partly—not completely—explained by the separateness within our system. If someone is labelled a mental health patient, they are treated in the mental health system, and consequently their physical health needs are neglected.

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[John Pugh (Southport) (LD)]

Let me begin by commending those who have spoken about their own problems today. I assure them that they have done their prospects no harm whatsoever. They have risen appreciably in the esteem of the House, although whether that is the key to promotion I do not know.

[Mr Kevan Jones]

I am grateful to the hon. Gentleman, but the use of language is very important when it comes to mental health. I do not consider it to be a problem. My own experience has made me stronger. I think we should be careful about how we use language: we should not describe mental health as a problem, because it is not.

[John Pugh]

I think that the expression used nowadays is “issue”.

[Sir Peter Bottomley]

The hon. Gentleman and I would probably agree that it is an experience.

[John Pugh]

We will settle for “experience”, then.

I congratulate the hon. Member for Loughborough (Nicky Morgan) on introducing the debate, although she omitted to mention the Mental Health Act 2007, over which the House laboured long and hard to, I hope, some good effect.

In the 18th century, it was possible to cross the river to Bedlam and gawp at people gesticulating, ranting, performing odd rituals, talking to no one in particular, exhibiting delusory beliefs in their own power, or expressing paranoid fears about their foes. The nearest 21st-century equivalent is probably Prime Minister’s Question Time. [Laughter.] That is not an entirely facetious point. The dividing line between robust mental health and mental illness is, in fact, a fine one. Statistics show that the bulk of people of working age who either report or are diagnosed with mental health problems are not, in general, those who suffer from the terrible scourge of schizophrenia. The hallucinations and delusions often associated with that disease currently affect less than 1% of the population, and are treated more benignly and more effectively than ever before. Moreover, numbers are not substantially on the increase.

Most mental health problems occur when the anxieties, the fears, the stresses and the dark moods to which we are all prone become insupportable, prolonged and disabling, and the individual is no longer able to cope in any ordinary sense but breaks down and loses control, social capacity and, sometimes, insight into his or her condition. That is on the increase: it is the major mental health challenge that we face.

Mental health is a genuine continuum. The mentally ill do not have viruses, germs, cellular patterns or physical impairments that the well do not have. They have the same gamut of emotions that we all have—often exaggerated, accentuated or uncontrollable, but in no way unique or uncommon. We all possess a shared vulnerability to mental health issues which could be described as a tendency to neurosis, managed with differing degrees of success at different times in our lives. That is why I took issue with some of the comments made by the hon. Member for Loughborough.

There is a nugget of truth in the American belief that we could all benefit from an element of psychiatry. As I have said, we share a common vulnerability, and for a variety of reasons—fairly complex in many cases—one in four, or one in six, citizens falls victim to that vulnerability. We have learned not to be too judgmental about those who do, and not to stigmatise them. We recognise that the vulnerability they display is often a product of circumstance, and that it is as frequently related to desirable traits—empathy and sensitivity, for instance—as to undesirable ones such as self-obsession or lack of self-control. However, although that recognition is now widespread, it does not eradicate stigma, nor does calling everybody “service users” as if they are some kind of consumer, and nor does saying mental illness is just the same as physical illness, because it is not.

The big problem for those with a record of mental health issues—particularly, perhaps, in respect of the workplace or getting off benefits and back into the workplace—is the bias of the wider world in favour of those who have not illustrated our common vulnerability. That bias is rather like having a—rational—preference for people with a stronger immune system. There are other vitiating factors at play, of course. People who suffer from mental illness often suffer from a lack of confidence, for example. There is also the fact, which has not so far been acknowledged, that a mental health diagnosis can sometimes be misused for employment and benefit reasons. The big problem is this bias and discrimination, however.

There are only two real remedies for that. One is better public education about what mental health actually is and what mental illness and frailty actually are. I would put more faith in the second remedy, however: having a public mental health campaign that is geared in positive directions, as described by the hon. Member for Loughborough. Having said that, we must acknowledge that the active pursuit of mental well-being is a bigger and more significant task than we currently recognise. Corporate Britain, business Britain and every public service in Britain needs to be seriously engaged with the Layard agenda and to accept that we need to promote well-being at work—including here in Parliament. We must create a wholesome workplace, and therefore bother about the happiness of the workplace and the individuals in it.

We may need to tackle a huge fallacy, however: the idea that we either have mental health or we do not, so we are either employable or we are not. That ignores the fact that many people in employment—in senior jobs, even—have mental health issues, some of which might not always be diagnosed. Sometimes they work them out in the office and the workplace in a wholly unsatisfactory way, and sometimes to the detriment of their colleagues—although not always, in certain professions, to the detriment of customers and profits. Sometimes people mask their symptoms and problems through alcoholic self-medication.

There was a time when employers would have walked away from considering issues such as personal safety at work, and there was a time when they would have walked away from issues of employment legislation and the rights of people at work. Nowadays, however, most employers are keen to stick “Investors in People” logos on their notepaper to show that they are a good employer in that respect. The next, and most obvious, stage is the pursuit of the wholesome workplace, in a move beyond the “Investors in People” initiative. That must be encouraged by public health bodies and by large public and corporate organisations. Indeed, to some extent it already is encouraged: 41% of large companies now have a mental health policy. That represents appreciable progress.

For most of us, work is where we spend most of our time, and it is where our feelings of self-worth are either confirmed or demolished—that is certainly true of this place. It is where people find meaning to their lives—although we do not always succeed in doing that here. Indeed, we in Parliament cannot honestly say our working environment is wholly conducive to good mental health.

Let me conclude by reiterating my key point: we cannot help people with mental health issues without making it manifestly clear that in everyday work and everyday life mental health is everybody’s issue.