Health and Social Care Bill

Lord Patel Excerpts

Wednesday 8th February 2012 Lords Chamber

Moved by

[Lord Patel]

1: Clause 1, page 2, line 6, after “of” insert “physical and mental”

[Lord Patel]

My Lords, it is a dubious privilege to speak to this amendment. I say “dubious” because the noble and learned Lord, Lord Mackay of Clashfern, is on a well-deserved rest and recreation leave and the noble Baroness, Lady Hollins, who is better qualified than me in this area, is unfortunately also detained on a lecturing commitment in Rome. However, I am pleased to say that the noble Lord, Lord Alderdice, whose name is also to the amendment, and who is much more knowledgeable on these matters than me, will no doubt speak later.

The House will remember that when we discussed this issue in Committee there was widespread sympathy for and acknowledgement of the need to recognise mental illness and accord it a similar importance as that accorded to physical illness. The noble and learned Lord, Lord Mackay of Clashfern, who tabled this amendment, wrote a note to me to say he was sorry that he would be away when it came up for consideration. He said that some time ago he was travelling with a lawyer colleague who had been a chairman of mental health tribunals for many years. He asked his colleague what was his impression of progress in this field. The reply was that it was not great compared with that in other health fields. The noble and learned Lord’s view is that it is desirable to emphasise the importance of mental illness and its treatment for the well-being of our people, and that it is wise to do so through this amendment to this comprehensive Bill. He feels right at the start of the Bill is the vital place to do so. Thereafter, the definition clause will carry this meaning where appropriate. The noble and learned Lord does not agree with the objection that if the provision is inserted at this point in the Bill, it must be inserted everywhere the issue arises. In his view, the definition will carry that burden and make later repetition unnecessary.

The amendment would place an explicit duty on the Secretary of State to promote parity of esteem between mental and physical health services. The duty would sit within his or her existing duty to improve the quality of health services. It also clarifies that the Secretary of State has a duty to promote a health service designed to secure improvements in the prevention, diagnosis and treatment of both physical and mental illness. The amendment would put the Government’s own commitment to parity of esteem between mental and physical healthcare on a statutory footing and make it clear that the Secretary of State is fully committed to improving the nation’s mental health services and the prevention and treatment of mental and physical illness and expects the NHS board and the CCGs to do the same.

When the Government launched their mental health strategy, No Health Without Mental Health, in February 2011, the Minister for Care Services stated that he wanted to see parity of esteem between mental health and physical health services. This was a recognition of the fact that, despite the prevalence of mental illness—one in four people experience a mental health problem during their lifetime—mental health has never received the funding or attention it needs. Progress in improving the quality of commissioning and services has been much slower for mental health. Parity of esteem is not defined in the document itself. However, it would be reasonable to expect that this would mean a recognition of the equal importance of mental and physical health and the need to consider both aspects of people’s health when they present with either physical or mental illness. I would expect this recognition to be evident in terms of access to mental health services and funding for services proportionate to the disease burden. However, this has not been the case.

Over the past 10 years things have begun to improve. For example, we have seen significant and very welcome investment in talking therapies under both the present and previous Governments—£173 million in 2007-10 and £400 million from 2010-14. However, given that mental health services started from a very low baseline, we simply cannot afford to go backwards—and talking therapies are only one aspect of mental healthcare. During previous spending squeezes—for example during the financial year 2005-06—mental health services have been unfairly and disproportionately targeted for cuts, perhaps because they do not enjoy the same level of public support and understanding as other services. I admit that I often push for cancer services and maternity services, so I pay regard to that.

However, mental illness is a leading cause of suffering, economic loss and social problems, and it is time to recognise and act on the plentiful evidence that good mental health underlines all health. Poor mental health is associated with diseases such as cancer, cardiovascular disease and diabetes; and poor physical health increases the risk of mental illness. In the current climate of scarce resources, expenditure reduction, welfare reform and cuts to legal aid—I might as well get all that in—mental illness and mental health problems are likely to increase. However, while mental illness represents 23 per cent of the disease burden, it accounts for only 11 per cent of the health budget. It is therefore vital that mental health spending should be proportionate to the need, and mental health must not be the poor relation of physical health.

More than one-fifth of the population in England experiences a mental disorder at any one time. An even larger proportion experiences sub-threshold mental disorder. Almost half of adults experience at least one episode of depression during their lifetime. Only a quarter of affected individuals receive any intervention, except those with psychosis. Compared with people with no mental health problems, men with severe mental illness can expect to live 20 years less, and women, 15 years less. A combination of lifestyle risk factors such as smoking and diet are higher, as are unnatural deaths such as those caused by suicide and accidents. Poor physical healthcare contributes to this premature mortality. If such a disparity of mortality rates were to affect a large segment of the population with less stigmatised characteristics, we would witness an outcry against the socially unacceptable neglect of that group.

While the amendments cannot solve all this, creating an explicit duty on the Secretary of State would set a clear expectation that commissioners need to give full consideration to the mental health of those with physical health problems, and to the physical health of those with mental health problems—and to give full consideration to mental as well as physical health. It is simply not acceptable for the mental health needs of children and adults to continue to be neglected.

There is an imbalance between mental and physical health in both healthcare and health promotion in many places. A better balance could bring a number of benefits to people living with, or facing the risk of, mental ill health. Health and social care policy should be developed with mental as well as physical health needs in mind. A duty to promote equality should encourage policymakers at all levels of the system to consider mental health alongside physical health, rather than making policy for the latter, and later adjusting to fit the former.

I know that the Minister is very involved with people in the area of mental health because I know that he has been a patron of several charities related to it, and he therefore has great sympathy towards recognition of mental illness and its treatment. I hope that his answers to the amendment will be such that there will be no need to seek the opinion of the House, and I look forward to his reply. I beg to move.

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[Lord Newton of Braintree]

My Lords, perhaps I may say that if it was me who my noble friend was referring to as being on his left, I am thrilled to bits by his rather more constructive response. I congratulate him.

[Lord Patel]

My Lords, I wish that I did not need to speak at this point because I am really quite torn. I know how sincerely all those who have spoken feel about this amendment, and about emphasising the need to promote mental illness as having the same parity as physical illness. At the same time, I know how sincere the noble Earl is, and therefore it is difficult not to accept what he has said and the promises he has made. None the less, the comment made by my noble friend Lord Walton is the one that has affected me most: what is the key objection to putting these two words at the front of the Bill to signify that mental illness is as important in its management as physical illness?

In my professional life I have dealt with physical illness, but I was always deeply affected whenever I had a patient suffering from postpartum depression or antenatal anxieties and sometimes psychosis; they were the most difficult to deal with. I would then have to seek the assistance of my psychiatrist colleagues.

[Lord Elton]

The noble Lord said that his noble friend was awaiting an answer to his question as to what was the objection? I have understood my noble friend to say that the objection was that it could actually make things more difficult because it would imply that there is a distinction between the two forms of medical treatment, which is exactly what we wish to negate.

[Lord Patel]

I did hear what the noble Earl said and I cannot say that I can accept that it would create difficulties if we included mental illness with physical illness. I do this with a very heavy heart, but I know that if I do not push the amendment, others will do so. On that basis, I think we should resolve the issue by seeking to test the opinion of the House.

--- Later in debate ---

[Lord Patel]

My Lords, I pay tribute to the noble Earl for how he has met our concerns in the Committee debate on education and training. The noble Lord, Lord Walton, mentioned Amendments 13 and 16. To me, Amendment 13 is crucial. The reason I degrouped them is because Clause 6 addresses the Secretary of State's responsibility for education and training. I hope that we will have the debate about the issues that he raises when we debate Amendment 13. I agree with the amendment of the noble Lord, Lord Turnberg—Amendment 16—which provides that universities need to take a greater part in education and training than they have hitherto.

[Lord Hunt of Kings Heath]

My Lords, as this is a new stage of the Bill, I should declare a number of interests which are also listed in the register; I am chairman of the Heart of England NHS Foundation Trust, a consultant and trainer with Cumberlege Connections, president of the British Fluoridation Society and of the Royal Society for Public Health.

I put my name to Amendment 2, tabled by the noble Baroness, Lady Finlay, which has perhaps not received as much enthusiasm as I would have wished from noble Lords, who have pointed to Clause 6. Behind her amendment is real concern to ensure that we will train enough health professionals in the years ahead and that they will be of sufficiently high quality. There is some history here. I very much support devolving as much as possible decisions about the commissioning of training places to local NHS organisations. I warmly welcome the work of Dame Julie Moore and her team, who have produced the report. She is chief executive of the UHB Foundation Trust in Birmingham and brings a lot of expertise to that position. Some noble Lords will have been to a seminar where the report was debated. I have no argument with its general thrust, but we know from experience that when money is tight, the NHS reduces the number of people that it trains and its training budget. That always happens and, a number of years later, the NHS then pays the consequences. If we are to have a highly effective National Health Service in future, we need to recognise that the quality of our professional staff goes to the core of what we seek to do. Therefore, it is right that the Secretary of State should be seen to have major responsibilities enshrined in legislation. That is the essential point of Amendment 2, whatever the technical deficiencies to which noble Lords have kindly drawn our attention.

In that regard, let me say that I welcome the government amendments in this area and the work of the noble Earl, Lord Howe. Of course, he is also responsible for research in the department, and I think that he well understands how the education and training of our professionals very much ties in to the research agenda. I know that we will come to research later tonight.

In relation to the other amendments in this group, I have already welcomed the government amendments, but perhaps I may pick on Amendment 63. It is right that the national Commissioning Board should have regard to the promotion of training of clinical staff in any provider from which it commissions services. There is essentially a parallel amendment—Amendment 104—which applies to clinical commissioning groups. The whole point here is to ensure that there is a level playing field. If, regrettably, the Government persist with this lunatic idea of a competitive approach within the health service, it is essential that when it comes to commissioning decisions all qualified providers contribute to education and training. It would be an absolute disgrace if clinical commissioning groups and the national Commissioning Board started to commission services from organisations that did not play their full part in education and indeed research. I hope that the noble Earl, Lord Howe, will make it clear that that is what his Amendment 104 means when it says, in parliamentary counsel terminology, that clinical commissioning groups must,

“have regard to the need to promote education and training”.

I take that to mean that the amendment does not permit CCGs to place contracts with qualified providers who do not make a contribution to education and training.

Overall, I echo the words of the noble Lord, Lord Walton, regarding the work of postgraduate deans and his question about their future. Where are postgraduate deans going to lie in the future? Are they going to lie in the local branch offices of the national Commissioning Board; are they going to be aligned with the clinical senates; or are they going to float free? I think we should be told.

I also echo the words of the noble Lord, Lord Willis, regarding the role of universities. It should not be an option; they need to be round the table. It needs to be what I would describe as a “hard partnership”. I think we are all well aware of the issues and concerns surrounding the quality and outcome of nurse training. The noble Earl, Lord Howe, himself has often commented on issues such as dignity, nutrition and so on, where matters have been raised by patients and there is concern about whether today’s nurses are getting the kind of training that is required. It is very important that those who commission from universities do so in as vigorous a way as possible and hold those universities to account. However, equally there has to be a partnership. The noble Earl, Lord Howe, will know about the intention to expand academic clinical science networks. That is a very good example of universities and the health service coming together, and we need to encourage that in the future.

Finally, the noble Lord, Lord Walton, raised a point about the duty on any willing provider regarding training or research. I think that I have covered that, but he also mentioned NHS foundation trusts. I am not aware of any situation in which NHS foundation trusts are ignoring their responsibilities but I certainly agree with him that, as they are more independent of the Secretary of State than other parts of the NHS, some assurances from the noble Earl in that regard would be welcome.