NHS: Mental Health Services

Lord Layard Excerpts

Monday 8th October 2012 Lords Chamber

[Lord Layard]

My Lords, I, too, am grateful to the noble Lord, Lord Alderdice, for securing this debate. I declare my interest as a national adviser to the IAPT programme and chair of the group to which the noble Lord, Lord Alderdice, referred.

We are now at a critical juncture in relation to the IAPT programme. On the one hand, we have some wonderful features. We have the Government’s commitment to parity of esteem for mental health, which is very important. For the out-service we have the Government’s commitment to providing treatment in 2015 for 15% of the 6 million people suffering from depression or anxiety disorders, which is a very important commitment. As part of this, the Government have also committed to training 800 therapists a year over a three-year period.

The issue is what is happening on the ground. Up to 2011, the programme was an extraordinary success. Starting from scratch it reached, within three years, 10% of those 6 million people. That is extraordinarily good going from a standing start. This is not a service that was being modified; it was created in a vacuum, which was a really major achievement. Equally, on the training side, 3,400 therapists were trained in evidence-based therapies, using a state-of-the-art national curriculum developed by the central team and its experts. The outcomes were also good. Recovery rates approached 50%, which was the target, and the programme has been extraordinarily successful in measuring the outcomes of its patients. In fact, it has accumulated the largest body of patient-reported outcomes, physical or mental, in the whole of the NHS.

All these achievements have been brought about by the fact that there was a central leadership with good administrators and a good network of experts co-ordinated within the Department of Health and by the extraordinary contribution and self-sacrifice of the outstanding clinical director, Dr David Clark—I must mention that because we have been extraordinarily privileged to have perhaps the world’s leading clinical psychologist leading this programme. It is therefore not surprising that the world’s leading scientific journal, Nature, last week acclaimed this as a world-beating programme. People all over the world are looking to it to see if it can continue developing.

However, although the programme is only half way through its development phase, its future is already in doubt and, as I mentioned, the Government are at serious risk of not achieving their commitments for 2015. In 2011-12 there were 530 training places, not the Government’s commitment of 800, and numbers are looking even more precarious in the present year. Services for patients are not expanding, as would be required to get from 10% to 15%, but are being cut in some localities and are standing still in others. At the same time, waiting times in IAPT are rising.

Also increasing is the problem, which was just referred to, of commissioners focusing, through their financing arrangements, more on those who need the least help—the easiest to help who can be dealt with cheaply. There is a serious dead weight if you give the help to the people who least need it. That will increasingly go on under these financial pressures unless serious steps are taken to stop it.

What can the Government do? As the services are locally commissioned, the Government have no way to force local commissioners to spend the money that was set aside in their baseline for IAPT in the spending review. They do, however, have tools, the first of which is the central guidelines embodied in the NHS outcomes framework. This is what commissioners read. They cannot read all that paper and prose but they can read the one sheet that contains 60 outcomes for the NHS. Where does IAPT appear in those 60 outcomes? It does not. That is just not good enough.

Depression is 50% more disabling than most of the chronic physical illnesses that are now a big focus for the NHS. Depression and anxiety account for at least one third of all morbidity in Britain. The NHS is there to deal with the mass of morbidity in the country, so how can it possibly be that the main treatment for those conditions is not in the NHS 60 outcomes? I agree that this is not a conspiracy, but it is a failure which happens because mental health so often gets overlooked. Unless we have IAPT outcomes within the NHS outcomes framework, it is nonsense to be talking about parity for mental and physical illness.

We have waiting time targets for all physical conditions treated outside general practice, but there are no waiting time targets for depression and anxiety. That is not parity of esteem either. There is also a huge problem with local commissioners paying less and less for therapy, leading to a bias against those in greatest need. We need a central initiative and national tariffs if we are to secure parity of esteem for serious mental illness as against physical illness.

I must come, finally, to the question of the central leadership of the programme, which is, as I explained, why it has succeeded. The programme is only half way through its development but its present coverage is 10% compared to the 15% to which the Government are committed. Even then, the programme will not have touched most of the 3 million people with physical conditions who are also mentally ill. This problem has not yet been tackled, although it is costing the NHS a huge amount in the physical healthcare budget due to the comorbid mental condition. The estimate is that something like £10 billion a year of the NHS physical healthcare budget relates to comorbid mental conditions that ought to be treated. Big savings could be made from that. We claimed in our report that at least half a billion pounds could be saved by extending psychological therapy to that group. Extending IAPT on that scale would cost the NHS nothing in net terms. On top of that, it would save the DWP and the Treasury the money on benefits, which would again repay the cost of the therapy. However, none of this will happen without central leadership. It really is just like that. The question is: what is being planned for the central leadership of the programme next April, when it ceases to be housed in the Department of Health? So far, we have had no public word on that critical question.

There is a real risk of a disaster in the making, not intentionally but by mistake. I have to ask the noble Earl three questions—not to embarrass him, because I know his heart is in the right place. However, I get heartrending letters from people every week and there are millions of people out there whose lives are at stake in all this. If I might, I should like to end with the three questions. First, what plans do the Government have for the central IAPT leadership team? That really is crucial. Secondly, will the IAPT outcomes be incorporated in the outcomes framework? Thirdly, will the Government introduce rights to waiting times in mental health as in physical health? I hope that the noble Earl can help us on all these points, either today or shortly hereafter.

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[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, I begin by congratulating my noble friend Lord Alderdice on securing this debate, and on raising the important issue of strengthening mental health in the NHS.

This is a timely debate. Wednesday is World Mental Health Day, a day which sends an important message across the global community: mental health is everyone’s business. As the noble Baroness, Lady Young, rightly emphasised, it is appropriate to turn the spotlight on mental health services at a time of huge structural and service reform across health and social care, when a lot of the attention has been focused on primary care and clinical commissioning groups. It is vital that mental health is woven in to the fabric of these reforms.

Before I respond in detail to the remarks made by my noble friend and other noble Lords, I want to take this opportunity to thank him and the noble Lord, Lord Layard, in particular for their lobbying, research, advice and support, which have done so much to set the standard for mental health services and drive system reform.

The recent report from the London School of Economics’ Centre for Mental Health, How Mental Illness Loses Out in the NHS, makes a compelling case for prioritising investment in mental health services and for treating mental ill health as seriously as physical ill health. Although we take issue with some of the content, we are in full agreement on these two central tenets of the report. Mental health simply cannot be an add-on or an afterthought. It costs £105 billion per year, to say nothing of the emotional toll that it takes on individuals, families and carers, so it must always be in the foreground when we think about health and social care. The messages are clear from people with mental health problems and their carers. They want to see a real difference in the range, quality and choice of services available. They want everyone to benefit from our mental health strategy, “No health without mental health”. This includes people with severe and enduring mental illness, those from minority ethnic communities and individuals who have offended.

They also want us to recognise the importance and expertise of family carers, who have so long occupied a shadowy position ill-served by legislation. This Government have committed themselves to fulfilling those wishes. Our new mental health implementation framework, coproduced with five leading mental health charities, sets out how we will do that. The framework translates the strategy’s vision into practical action for specific organisations. It outlines what the new health and care system will mean for mental health; and it shows how the mental health strategy fits with the three outcomes frameworks for the NHS, social care, and public health, and how each will help to deliver the other.

On top of that, the draft mandate to the NHS Commissioning Board, published for consultation on 4 July and mentioned by my noble friend Lady Tyler among others, also emphasises the importance of a new focus on mental health. This is reflected both in a dedicated objective on mental health, and in objectives for improving performance against the NHS outcomes framework. Overall the mandate suggests a culture-change on mental health throughout the NHS.

I simply say to the noble Lord, Lord Layard, that the Commissioning Board is discussing future arrangements with Ministers, but in the end, as he will recognise, it will be up to the Commissioning Board to deliver its commitments, and not for the department to second-guess the board. The noble Lord, Lord Layard, has said that the outcomes framework contains almost nothing on mental health. This is simply not the case. The 2012 framework contains three improvement areas which relate specifically to mental health—

[Lord Layard]

I was referring only to it containing nothing about the outcomes from IAPT, which is a very big service. There is nothing about recovery from depression and anxiety.

[Earl Howe]

I am grateful, and I will come on to that point. It is just worth rehearsing that there are three improvement areas: premature death in people with serious mental illness, the quality of life of people with mental illness, and the experience of healthcare for people with mental illness. In addition, many of the indicators relate to all patients and therefore apply equally to mental health patients. We are keen to strengthen the outcomes framework in relation to mental health in general, and recovery from mental illness in particular. We have recently begun work to define what good recovery from mental illness looks like, recognising that for some people this will mean the effective management of symptoms rather than a cure, and to develop proposals for how this might be measured. Our aim is develop measures that are suitable for inclusion in the NHS outcomes framework.

I know that some, like the noble Lord, Lord Layard, have been concerned that not enough is being done to meet the needs of people with long-term physical health conditions who also have mental health needs. We are addressing that. One of the measures by which we will gauge the success of the NHS Commissioning Board will be its ability to improve care for people with long-term conditions. This obviously includes people who have both physical and mental health problems.

Moving on to IAPT, we are also addressing the criticism that psychological services are too difficult to access in the first place. The operating framework for the NHS in England clearly states that the NHS should carry on expanding access to psychological services as part of the improving access to psychological services or IAPT programme. The noble Lord, Lord Patel of Bradford, said that change on the ground was hard to discern. The coalition Government have overseen a big increase in the number of people benefitting from IAPT services: 528,000 people entered treatment in 2011-12, more than double the number in 2009-10.



These new services are achieving recovery rates of more than 40% and are on track to meet recovery rates of at least 50%. We are investing £32 million this year in training new therapists to meet the demand. More than £400 million will be channelled towards talking therapies so that adults with depression and anxiety across England can get access to NICE-recommended psychological therapies. That investment will also help to fund the expansion of psychological therapies for children and young people—I shall say a bit more about that in a moment. We are also looking at how older people, carers, people with long-term physical health problems and those with severe mental illness can get better access to evidence-based psychological therapy.

Contrary to the statements quoted by the noble Lord, Lord Patel, we have no evidence of underinvestment by the NHS in IAPT services. On the contrary, funding is going up. At present, 149 out of 151 PCTs commission an IAPT service, which is nearly 100 services across England covering more than 95% of the population. However, in order to secure consistently good services, there needs to be a fundamental change in the way our society views mental health. Both individuals and organisations need to change some views that on occasion are deeply entrenched. We have commissioned the Royal College of Psychiatrists to look at how we can encourage everyone to ascribe the same importance to mental health and physical health. The work involves many leading royal colleges, professional associations, charities and others. It includes concrete examples of positive changes that parity would help to bring about. The college has already begun to collect and develop examples of both good and bad practice, and its final report will be available shortly.

My noble friend Lord Alderdice mentioned skills. It is important to note the influence that the royal colleges can wield in improving mental health services. The Royal College of General Practitioners has identified improved care for people with mental health problems as a training priority. It has proposed enhanced training for GPs, designed to increase clinical, generalist and leadership ability. I welcome its suggestion that mental health should be a central part of that enhanced training.

The GP curriculum and examination system will be changed to accommodate the new system of training, so we can look forward to newly trained GPs with an extremely broad knowledge of mental health issues. That is an excellent example of the role that groups outside government can play.

There have been a lot of stories about spending on mental health services being cut, but spending on mental health has stayed broadly level in cash terms. Although this has meant a very slight reduction when compared with inflation, this is quite an achievement given the huge cost pressures on the NHS and quite a different picture from the one that is often claimed.

My noble friend Lord Alderdice and the noble Lord, Lord Patel, questioned how we know that the £400 million is being spent on IAPT. The NHS is accountable to the department for results, not for spending money in line with predefined pots; it is outcomes that count. We have made sufficient money available to the NHS to maintain the expansion of IAPT. We have made very clear what results we expect from that investment, but local commissioners must be in a position where they decide how to use their budgets to meet the health needs of their local populations. That is not something that we can decide in Westminster.

The noble Lord, Lord Layard, and the noble Baroness, Lady Emerton, spoke about the slowing down of this effort. Preliminary figures for the first quarter suggest that the expansion of talking therapy services is slowing in some parts of the country. We are looking at the data to make sure that we understand whether that is temporary or something more serious, but it is clear that the picture is very variable across the country.

I have just received a note to say that my time is running out. I say now that I will write to all noble Lords whose questions I have not covered, but I shall in the time available cover as many more as I can, in particular on children’s services, which was a theme of my noble friend Lady Tyler and the noble Baroness, Lady Young.

Children’s mental health is a priority for this Government. The Government’s mental health strategy takes a life-course approach, recognising that the foundation for lifelong well-being is already laid down before birth and that there is much we can do to protect and promote well-being and resilience through our early years and adulthood. We have invested up to £54 million over the four years from 2011-12 to 2014-15 in evidence-based practice, such as children and young people’s IAPT, undertaken work to introduce payment by results for CAMHS, which my noble friend Lady Tyler referred to, and announced plans for a children’s health outcomes strategy.

Children and young people’s IAPT is a service transformation project for CAMHS, extending training to staff and service managers and embedding evidence-based practice across services to make sure that the whole service, not just the trainee therapists, use session-by-session outcome monitoring.

My noble friend Lord Alderdice and the noble Baroness, Lady Meacher, questioned whether there was a bias towards IAPT to the detriment of other services. Although I agree that there are different approaches to providing psychological therapies, it is local commissioners and not central government who are responsible for determining which services should be funded. I am happy to write on that theme, about which I have further information—as I do about charities, a point raised by the noble Lord, Lord Wills, who also asked me about the mental health legislation resource. I have a note that I would gladly have read out, but time has eluded me. I will also gladly write to the noble Lord, Lord Patel, about prisoners’ mental health and to my noble friend Lord Alderdice about patients being locked in at night at Broadmoor, as well as any other points that I have not covered. I am very grateful indeed to all noble Lords who have spoken in what has been a most illuminating and helpful debate.