Health: Parity of Esteem

Lord Lansley Excerpts

Monday 28th November 2016 Lords Chamber

[Lord Lansley (Con)]

My Lords, I congratulate the noble Lord, Lord Alderdice, on securing this short debate and on the way he introduced it. He set a very helpful frame for it. It is fundamentally not just about funding and structures, but about culture and attitudes. That is what we are aiming for, although I confess that, not for the first time, I will need to talk about funding and structures as well. Perhaps they are entirely complementary.

The noble Lord was kind enough to refer to back to 2011 and the inclusion in the Health and Social Care Act of language intended to demonstrate the commitment to providing health care services to tackle both physical and mental illness. Of course, it was not the first time that public policy had set that objective. It was simply intended to reinforce the February 2011 strategy document, No Health Without Mental Health, published by myself and Paul Burstow, who, as the noble Lord Alderdice, has just said, has been his colleague and was mine at the time. I pay tribute to his work on the document and indeed on the Care Act 2014 which was passed subsequently.

The point about No Health Without Mental Health is precisely the point made by the noble Lord in his introduction to this debate: we completely mislead ourselves if we see physical health and mental health as occupying in any sense different places for us as individuals and us as a society. We cannot have one without the other. In truth, I suspect that if we want to make the greatest possible progress in improving the health of the nation overall, it is in improving mental health that we can secure the best potential return. For young people suffering from serious mental health problems, the impact on their lifetime health and life chances is dramatic. The premature mortality of those with severe mental illnesses is clear, and this is probably the group in society on whom we could make the greatest impact if we could reach out and treat them successfully at an earlier stage. People are not dying because of their mental illnesses; they are dying because of the range of physical illnesses and lack of physical health which are the concomitants of their severe mental illness.

That is why No Health Without Mental Health was the title chosen for the document. Because of that thought, the strategy set itself the objective of trying, as we put it, to “mainstream” mental health into the NHS. It is a fact of NHS life since its establishment in the 1940s that mental health has always been regarded as something separate and different, but frankly it is not. It is a single part of the picture of how we deliver NHS services. Our objective, as part of the structural process, was to try to engineer mental health services into the mainstream provision of NHS services. However, we are still a long way from that. Mental health is not treated in the same way as other services. But we put that into public policy in February 2011, when we said:

“We are clear that we expect parity of esteem between mental and physical health services”.

It was a cross-cutting strategy that was intended to deliver that parity.

As the noble Lord pointed out, why do I and all other former Secretaries of State going back 20 years feel a sense of distress and sometimes despair about our ability to produce precisely that result? I think the answer is that the structures, funding and culture have not yet accepted that mental services should be brought into the mainstream, with all the benefits that that would bring. In my experience as a Secretary of State, mental health trusts were often extremely well run organisations, even by comparison with other community healthcare services. That is why I was so disappointed that the Uniting Care Partnership contract for Cambridgeshire and Peterborough, which faced severe problems from the outset and then collapsed, did not bring acute community and mental health services into one organisation, which would have been really useful.

We all support and want integration of services, but it is not happening in many places, and even where people put the services under a single umbrella, they often do not achieve integration of the professions. Least of all do they provide the integration that should be at the heart of the patient experience, so that people feel that health services are being provided by an organisation that works around them, not to its own structures and definitions. We have a long way to go to make that happen. Another real concern is that we have failed to achieve integration, notwithstanding successive requirements in recent years from government and NHS England for commissioners to increase funding for mental health services at least as fast as for the service overall.

I have to say that, although there were some announcements in September by NHS England and NHS Improvement, the structure of funding to the National Health Service from commissioners plays a part. Most of the time, most of the NHS is funded on the basis of tariff. To that extent, in so far as somebody receives a service from a provider, the provider has recourse—sometimes not enough, they think—to the commissioners to provide for that activity. Mental health trusts are pretty much still all under block contracts. As I said, an effort has been made since September to extend tariffs into mental health services. It should be done on the basis not of episodes of care, but of bundled care and care pathways. When that happens, it will enable mental health trusts to escape from this situation: because commissioners know they have to pay for the tariffs, such trusts are often provided with the residual sum, which means they do not get the funding they could for the activity they undertake.

My colleagues and I could see some of the problems: the number of suicides among young men aged under 45; people having to travel great distances to access care; and rising levels of mental health problems among young women. These and other issues are presenting us with problems. We know we can change the culture. Time to Change, for example, was a very successful programme that continues to be extremely useful, and we now have access standards for mental health services. However, I ask the Minister to take back these questions. How much progress has been made so far in 2016-17 in securing those access standards? How much further do we have to travel? When will we be told what the objectives will be in 2017-18 and 2018-19 for measuring progress towards the 2020 objectives in the mandate for securing access to mental health services?

There is more we can do. We can extend the access standards. We need more quality standards applicable to mental health—the forward programme has only one, although the number published by NICE is valuable. It feels to me and my colleagues that we have much further to go and we need to inject a sense of urgency. That is why I welcome the debate.