Health and Social Care Bill

Lord Walton of Detchant Excerpts

Wednesday 8th February 2012 Lords Chamber

[Lord Alderdice]

My Lords, the noble Lord, Lord Patel, has characteristically underplayed his own grasp of this important area, but, as noble Lords have heard, he has on his own behalf and on behalf of the noble and learned Lord, Lord Mackay of Clashfern, and the noble Baroness, Lady Hollins, presented an elegant, informed and very persuasive case for the amendment, to which I have put my name. In many ways, there is not much to say other than to support him. However, when noble Lords say that in your Lordships' House, it is often because they actually have quite a lot to say, and I shall say a few words.

On 2 November last year in Committee, your Lordships debated three amendments which would have placed the responsibility on the Secretary of State, the national Commissioning Board and all clinical commissioning groups to regard mental health on the same basis as physical health. That is to say that they should give full consideration to all those suffering from mental illness in the same way as they would those suffering from physical illness.

One reason for trying to insert such a commitment into the Bill was that, despite the efforts of the previous Government—to whom the noble Lord, Lord Patel, is quite right to pay tribute—to address the needs of people with mental illness by allocating more money for talking treatments, on which the coalition Government have substantially built, as the noble Lord said with reference to the legal friend of the noble and learned Lord, Lord Mackay, out there in the real world, mental illness and problems of mental health do not get the same attention and concern. As we said in the debate in November, many people think of mental illness as a subset of illness, like cancer, diabetes, or whatever, but it is not. It is a quite different aspect. When you fall ill with something physical, something happens to you but your personality and your self are not affected; but when you fall mentally ill, the very essence of your self is affected. That is a very different business. It frightens people. They often turn away from paying attention to it because they are so troubled by it. The provision required is different. Often, much more than is the case with other illnesses, a whole range of services has to come together to provide treatment and support.

Our concern in that debate—which was supported by noble Lords on all sides of the House; no one spoke against—was that all the efforts until now have been less than fully successful in building up the regard and esteem in which mental health and mental illness is held. So the proposition for the amendments was not a belief that there was a particular technical flaw in the Bill which meant that mental illness would not be addressed; we are very much aware that it is addressed in the Bill. That is not the problem. The problem is: how do we find a way continually to bring mental illness to the attention of commissioners? The noble Lord, Lord Patel said, as was said in the November debate, that in times of financial pressure and austerity, the tendency is to pull back financial commitment from those areas where there is least pressure. When people are physically ill, they can often nevertheless continue to exert pressure; but when people are mentally ill, they often do not give due regard to themselves, never mind press for the needs of others who are suffering from similar disorders.

Our concern is not about those three specific amendments but the principle. The noble and learned Lord, Lord Mackay of Clashfern, went away and produced a single amendment. The noble Earl was kind enough to give a considerable amount of time to me and the noble Baroness, Lady Hollins, to discuss the question. A concern was expressed by him and some people in the department that if one included this in one place, one would have to put it in every place because otherwise the implication would be that it applied only to the issue to which it refers directly. I have to say that the noble and learned Lord, Lord Mackay of Clashfern, was wholly unimpressed with that argument. As he is a former Lord Chancellor, I think one takes that pretty seriously.

The point is that we must find some way in which to make it absolutely clear beyond peradventure that concern for those who have mental health problems is every bit as great and the responsibility on commissioners is every bit as great to ensure the proper provision of services. One reason why this comes up as the very first amendment Report is that we want to ensure that in all aspects of health care, mental health care is attended to: no health without mental health and indeed, as the Royal College of Psychiatrists’ report said, no public health without public mental health.

It is regrettable that the Royal College of Psychiatrists, of which I am a member, has over the past few days been saying that the whole Bill should be set aside. That is not really a helpful way of engaging in these kinds of questions. The college knows perfectly well that the Bill is not going to be set aside—in fact, it would not be at all helpful if it were. I have seen these kinds of situations in other places, with people polarising in an unhelpful way. I appeal to the Minister, to the Royal College of Psychiatrists and to others who are interested and concerned in this field to find a way to get together again before the completion of the Bill to ensure that the concerns that we are expressing are reflected in a cast-iron fashion. It is a question not of these particular words or of this particular amendment but of receiving solid assurances so that we and those who care for people with mental illnesses, as well as those who suffer from such illnesses, can be confident about the new NHS.

[Lord Walton of Detchant]

My Lords, in rising briefly to support the amendment so ably proposed by my noble friend Lord Patel and supported by the noble Lord, Lord Alderdice, I ask the Minister one very simple question. In Clause 1(1)(a) the Bill talks about the,

“physical and mental health of the people of England”,

and says that the health service must be “designed to secure improvement” in that health. What on earth could the objection possibly be to inserting in paragraph (b) at line 6 the unexceptional words listed in the amendment? They simply stress the crucial importance of mental as well as physical illness. How on earth could this be construed as doing any damage whatever to the Bill? It is something that I hope very much the Government can be persuaded to accept.

[Lord Carlile of Berriew]

My Lords, I should like to say a word on behalf of those who have had to care for family members—often a young member of the family—who have suffered from severe mental illness. Those who have suffered that experience—and I am one—know how marooned they feel when they find that someone in their family has a serious mental illness. If somebody has a broken leg, you can locate the leg and take the medicine. If somebody has even cancer, it may not be curable but at least you have the knowledge of the location or locations of the cancer and the topical treatment that is to be applied to it.

The problem for families who experience in their midst mental illness is that no medicine can be applied topically to the place where the hurt or illness is taking place. The prognosis is uncertain, the mortality rate is depressingly high and usually at the hands of the sick person, and accessing good health service facilities is quite chancy, I am afraid. There is a real postcode lottery with mental health treatment. If, for example, you live in a remote rural area, only some therapies will be available and they may be the wrong therapies, particularly if the patient is a child or adolescent suffering from serious mental illness. Therefore, I simply say to the Minister who, as has already been said, cares deeply about these issues, that the adoption of this very simple amendment, as the noble Lord, Lord Walton, rightly described it, would send out such a telling message of support to families who have to care for people who suffer, perhaps temporarily, from mental illness that it would be seen as a declaration of purpose by this Government.

--- Later in debate ---

[Lord Willis of Knaresborough]

My Lords, I support government Amendments 61 and 104. As regards Amendment 2, which the noble Baroness has introduced, Clause 6 adequately describes the duties of the Secretary of State in relation to education and training. My noble friend the Minister has done an incredibly important job in recognising the real anxiety that existed at Second Reading about education and training. Indeed, we are grateful to the noble Lord, Lord Walton, for withdrawing his amendment at that time as that has enabled major discussions to take place on the issue.

Government Amendments 61 and 104 bring us to the heart of who will be driving much of the education and training—that is, the national Commissioning Board and the local commissioning groups. In fact, neither of these groups seems to have any responsibility for education and training, even though, as the noble Lord, Lord Turnberg, rightly says, they will be right at the heart of commissioning the healthcare required, whether it is in an NHS setting or a private, approved setting. That appears to be an omission in the Bill.

Although I have much sympathy with Amendment 109 of the noble Lord, Lord Turnberg, and he is right to point out that there is a requirement on private sector providers or, indeed, third sector providers, to engage in training, I hope that when the Minister winds up on this group of amendments he will point out the advantages to those providers of engaging in education and training. Indeed, he has privately assured many of us that they are more than willing to do so because they cannot become qualified providers unless they are engaged in cutting-edge training and education.

In Amendment 109, the noble Lord, Lord Turnberg, raised the important issue of the involvement of universities. It worries many of us that the universities which have been very much at the heart of education and training, particularly postgraduate education and training, appear to be sidelined in the new architecture of the Bill. Frankly, that is unacceptable. It should not be for local employers to decide whether or not they want a university to be involved; it should be a requirement for universities to be involved. We must not have a situation where universities are regarded as predators in relation to education and training, as they are fundamental to it. If research is a fundamental part of the architecture of the Bill and of improving patient care, frankly, it is absurd to have universities outside that remit. Therefore, I hope that when the Minister responds he will assure us that universities are part of the solution—as the noble Lord, Lord Turnberg, rightly said—and are not seen as part of the problem.

[Lord Walton of Detchant]

My Lords, I have just counted that in the course of the past few weeks and months I have attended 28 seminars, group discussions and personal meetings with Ministers, the Bill team and others. That was extremely useful. We have spent a lot of time discussing education and training. I pay warm tribute to the Minister—the noble Earl, Lord Howe—and his team and colleagues for the way in which they have responded and listened to many of the concerns which we have expressed about these problems. The Government have tabled a number of very helpful and constructive amendments. However, I seek to ascertain whether they meet all our concerns.

I know that the noble Lord, Lord Willis, will say that our earlier concerns about research and its role in the NHS have been completely met. I agree with him entirely. We are satisfied on that point. However, in relation to education and training, I said at Second Reading that since the health service began, undergraduate training of doctors, medical students and dental students had always been the financial responsibility of the universities, but that it had always been the responsibility of the NHS to provide the clinical facilities in hospitals and general practices of the United Kingdom for the training of those undergraduate students. Of course, in more recent years, the newer universities—the former polytechnics—have played a major role in the training of other healthcare professionals such as nurses, physiotherapists, occupational therapists, speech and language therapists and others. That commitment has been totally accepted.

However, postgraduate training of doctors, as the noble Lords, Lord Turnberg and Lord Willis, have said—those who are training to become physicians, surgeons, psychiatrists, and specialists in any branch of medicine—is the financial responsibility of the National Health Service and has been from the very beginning of the NHS. At the same time, the NHS has employed postgraduate deans who have been very helpful and responsible in helping to provide that training. It has also been monitored throughout by the royal colleges and faculties that have provided the content and curricula for the training of these groups of specialists. It is crucial that that interrelationship of all these bodies be enshrined in the Bill, even when Health Education England comes into being. I am mildly surprised that all the amendments grouped with Amendment 2 deal with education and training, but so too do Amendments 13, 16, 62 and 106 that are equally important and crucial to this whole programme.

I therefore ask the Minister whether he is satisfied that in the amendments that the Government have tabled, or in regulations that he can assure us will follow, the responsibilities of the universities and other institutions of higher education will be enshrined and clarified. Is he satisfied that through the postgraduate deans and the clinical senates—wherever they are housed, or whether they are housed with the National Commissioning Board and its outreach into parts of the country—the responsibilities of the royal colleges and faculties will also be enshrined, and the postgraduate deans will thereby continue to supervise the programmes? Is he satisfied—and this is crucial—that independent foundation trusts and any qualified providers that are providing NHS services will be required to accept responsibilities for the training and education of healthcare professionals, just as NHS hospitals, general practices and other NHS institutions are?

It is crucial that these issues are confirmed, and I trust that the noble Earl will be able to tell us that in the government amendments, and in regulations that may follow, all our anxieties about these major issues will be accepted and covered to the benefit of the healthcare workforce and the National Health Service overall.

[The Earl of Listowel]

My Lords, I rise briefly to pay tribute to the noble Earl, Lord Howe, and his colleagues for giving this most important issue such great attention since the Bill arrived in this House.

I wish to look at the experience in social work, where there has been great deterioration in the attention given to the professional development of social workers. I remember reading a letter from the noble Lord, Lord Hunt, when he sat on the Front Bench a few years ago, acknowledging the fact that newly qualified social workers were being placed in situations where they had too large a case load and were not being properly supervised. Fortunately, some steps have been taken to address this, but there is clearly still a long way to go on supervision of social workers, and the culture and state of morale of social workers has for many years been eroded by the lack of attention to their professional development. There was a time when there was good professional development; so it can happen, and it could happen in the medical professions.

Perhaps I may draw attention to the experience of teachers in Finland. This is particularly relevant to the Minister’s and the Government’s desire to increase autonomy within the health service and devolve responsibility down to the professionals closest to the front line. About 20 years ago, Finland reviewed its education system and decided to emphasise the professional development of its teachers. It decided to select its teachers very carefully, and now all practising teachers have a masters qualification before practising with children. Only one out of 10 applicants for teacher training places is accepted: there is huge competition to get on those courses. A few years ago, when PISA started publishing league tables of education system performance across the world, the Finns came out top of the numeracy, literacy and science tables, not just in one year but in successive years. Teachers are given a huge amount of respect within their society, very good professional training and development, and are well recruited. There is no inspection of the education system—teachers are so well trusted to do the best for children.

I pay tribute to the noble Earl and colleagues for giving this the best possible attention in the course of proceedings in your Lordships' House.