Psychosis: Early Intervention

Paul Williams Excerpts

Thursday 15th March 2018 Westminster Hall

[Dr Paul Williams (Stockton South) (Lab)]

It is a pleasure to serve under your chairmanship, Mrs Moon. I congratulate the right hon. Member for North Norfolk (Norman Lamb) on securing this debate. It is a subject that we are both passionate about, as are many people in this room. I pay tribute to the commitment that he made to mental health services during his time as a Minister and beyond.

Psychosis can be a terribly destructive condition. When it starts in adolescence, as it does for most people, people can lose out on schooling, relationships with friends and family are strained and the foundation on which the rest of people’s lives will be built is severely tested. Psychosis is not just about the symptoms—the delusions, hallucinations and suspiciousness that people feel. It is a social condition too. It often leads to a withdrawal from society—avoiding friends, avoiding leaving the house, losing schooling and losing work—and that is why it is such a pernicious condition. It can harm somebody’s life chances. It is a condition that leads to lost opportunities.

I am pleased that the right hon. Gentleman has drawn parallels between psychosis and cancer. We have not conferred, but I am also going to do so. We see how good cancer services are. It is important to have that comparator and to hold mental health services to the same standards as physical health services. We should think about psychosis in the same way as physical health services think about cancer. As soon as somebody shows signs of psychosis, they should have rapid—two-week—access to expert diagnostics. If the diagnosis is made, it is right that they get a superb package of care to give them the best possible chance of recovery. That care includes psychological therapies, medication, help with their physical health and, of course, rehabilitation.

If somebody receives that rapid package of care and support, there is half a chance that they will get back into education, employment or an apprenticeship. The rest of their life will be radically different. However, if they do not get that care, support and treatment, the figure for that drops to between 7% and 12%. That is what happens to people who do not get that package. If there was a pathway for cancer that improved survival and recovery from 10% to 50%, we would all know about it and fight for it. I am pleased that within this room there is the same passion and commitment to early intervention in psychosis.

The right hon. Gentleman outlined some of the costs to society of untreated and unmanaged psychosis, but I have a few things to add. Some 65% of all admissions to in-patient mental health units are for psychosis. The police spend increasing amounts of time detaining people under section 136, many of whom have psychosis. A lot of homelessness is associated with psychosis, and many prisoners have or had psychosis. As well as costs to society, there are also big costs to the individual. A person with a severe mental health problem such as psychosis will die, on average, 20 years younger than someone who does not. They are not dying of the psychosis; they are dying of physical health problems that are caused by their underlying mental health problems.

It is important that we are having this debate, but it is unfortunate too. In September 2016, the right hon. Gentleman led a similar debate on this very subject, and 18 months on we are learning that many of the things raised in that debate are still not happening. During that debate, the then Minister said:

“To improve access to NICE-recommended psychological therapies, we have to ensure that there are the staff numbers and the appropriate skills mix to deliver the full range of treatment to those who need it.”—[Official Report, 7 September 2016; Vol. 614, c. 163WH.]

Yet the survey conducted for the right hon. Gentleman’s recent report highlighted some worrying trends around resources and staff numbers. Many patients are not receiving the full range of treatments and interventions that should be included in the specialist EIP care package. Many trusts say that they simply do not have the staff and resources to meet demand.

I return to the analogy with cancer. The Government’s ambition is that 50%, rising to 60% by 2020, of people aged 14 to 65 experiencing a first episode of psychosis should have access to a NICE-compliant care package. If we were to replace the word “psychosis” with “cancer”, there would be outrage at that target. Why should it not be 90% or 95%? Why should the ambition not be 100%? If we were talking about cancer, we would already be hiring the radiologists, laboratory scientists, surgeons, nurses and technicians that we need for the pathway. I want to give credit where credit is due. Setting a 50% standard is at least a step towards achieving parity of esteem, but that ambition is clearly not yet a reality.

NHS England’s data show that more than 60% of patients start treatment within two weeks of referral. However, if we look at the data in a different way and ask people who have started treatment how long they waited, the figures paint a very different picture. In January 2018, even though 722 patients had started treatment within two weeks of referral, 1,344 patients were still waiting to start treatment, and more than 700 had been waiting more than two weeks. We are talking about figures, but those figures represent people—more than 700 people who were waiting in January of this year. Often these are young people who are not going to school because of new mental health problems that could be managed. During that time relationships are breaking down, people are losing their jobs and people’s life chances are being harmed.

There is regional disparity as well. The north of England, where my constituency of Stockton South is, has the lowest proportion of pathways completed within two weeks of referral and the highest number of total referrals still awaiting treatment. It seems that we have not yet put sufficient resources into our mental health services for the psychologists, occupational therapists, mental health nurses and care co-ordinators who are important to implement this pathway. I have to say that the staff who are working in this area are doing amazing work and transforming lives. I would like to thank them for what they do, but this now needs to be taken to another level and delivered to a much greater scale.

The right hon. Gentleman’s research shows that mental health trusts invest, on average, just half the amount that NHS England estimates is needed to provide EIP in line with NICE guidelines. As he stated, only 29% of trusts say that they are able to offer their patients the full NICE package of care. I urge the Minister to acknowledge that service providers still have ground to make up, and to recognise that they need greater support and resources to do so.

I really hope that the Minister responds with a plan to make things better for the people who we all know are still not getting the service that they need. I have no doubt of her personal commitment to improving mental health services, but she must match rhetoric with ensuring that commissioners are actually putting significant amounts of extra money into mental health services on the ground, and that providers are turning that cash into services that meet the needs of these priority patients. If this were cancer instead of psychosis, we would be doing it—let’s make parity of esteem a reality.

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

It is a pleasure to serve under your chairmanship, Mrs Moon. I congratulate the right hon. Member for North Norfolk (Norman Lamb) on proposing this debate to the Backbench Business Committee—a proposal for which I was a signatory—and securing this important and timely discussion.

The right hon. Gentleman and I have shared many platforms in supporting joint campaigns, and we have debated often the state of our mental health services. We have come to expect from him a level of forensic detail, commitment to improvement and genuine compassion for those with severe mental illness, and today he has not disappointed. We may have very small differences in approach or policy, but he and I share a big-picture commitment to world-class mental health services in this country; to genuine, tangible parity of esteem—real equality—between physical and mental health services; and to a transformation in the way that we view mental illness, talk about mental illness and treat those with mental health conditions.

As with many other forms of mental illness, all the experience and evidence point to the fact that the best time to intervene in cases of psychosis is as soon as possible. The work of Professor Patrick McGorry in Australia and proponents of early intervention in the UK clearly shows that early intervention can have a huge impact on the health of the individual patient, with more chance of them living with conditions in a managed way and ultimately more chance of their recovery.

I echo some of the right hon. Gentleman’s points about the benefits of getting back into employment and the importance of accessing individual placement and support. That is a well-evidenced measure that has already made a tangible difference to many people living with mental ill health. I will reflect on the experience in my area, Merseyside, where Mersey Care provides the majority of mental health services, including early intervention in psychosis. It did an audit of all the patients that it looks after in both the community and in-patient services. It is staggering that just 3% of their patients are in any form of employment. If we compare that figure with people in physical health services, the inequality—the massive disparity—when it comes to mental health is a great concern. That strikes at the heart of the issues that we are discussing.

It should not surprise hon. Members that the earlier we treat any condition, be that a mental or physical health condition, the more likely we are to get a positive result. In terms of system reform in the health service, early intervention clearly fits into the mantra of prevention being better than cure. I have said it before, but I will say it again: if people are not convinced of how important this is by the moral and social reasons, the financial and economic consequences of not contending with mental health sooner should be enough.

For the NHS to be sustainable in the long term, when it will increasingly have to contend with lifestyle-related diseases, we need a seismic shift from treating diseases and conditions when they present in crisis in their most acute forms to a system that allows us to detect them in their earliest stages, to manage them with early interventions and to do everything to avoid certain conditions in the first place, although that is not always possible. That is as true of mental illness as it is of cancer, cardiovascular disease and coronary heart disease.

The issue is not just health outcomes, but the impact that psychosis has on the totality of an individual’s life and their opportunity to be involved in education, employment and training, to maintain relationships with family and friends, to own a home or maintain a tenancy, to be able to go to work and to not be in our criminal justice system. Those outcomes have far-reaching and long-term consequences that are not contained solely within the Department of Health and Social Care, although a Health Minister will respond to today’s debate.

With that in mind, in February 2016, the Labour Front Bench, including me as the then shadow Minister for Mental Health, welcomed the inclusion of the access and waiting time standard for early intervention in psychosis in “The Five Year Forward View for Mental Health”. The commitment was that NHS England should ensure that by April 2016, 50% of people experiencing a first episode of psychosis had access to a NICE-approved care package within two weeks of referral, rising to at least 60% by 2020-21.

It is important to reiterate that laudable target and ambition. It was modest, but it was an important first step and it was welcomed across the House, so it is with heavy hearts that we review progress since then, and realise that the system is failing to reach the target stipulated in the “The Five Year Forward View for Mental Health”.

Once again, we should recognise the detailed work of the right hon. Member for North Norfolk in unearthing the emerging picture from across the country. Every Minister’s worst nightmare is the ex-Minister armed with the tools of freedom of information requests and parliamentary questions, and who knows the darkest secrets at the heart of the Department.

We now know that the access and waiting time standard for early intervention in psychosis is not being met. Too many providers cannot offer the full NICE-approved package of care. There is variation across the country, with, as ever, the poorest people in the poorest parts of the country receiving the poorest levels of service. That real inequality is a social justice issue.

I echo the concerns expressed by my hon. Friend the Member for Stockton South (Dr Williams) about the figures for his constituency in the north of England. The north of England commissioning region has the lowest proportion of completed pathways and the highest number of total referrals still awaiting treatment—two thirds. That should be a serious concern for us all. The inverse care law, first identified some 40 years ago, is alive and kicking when it comes to mental health services.

The latest picture published by NHS England shows that far from the steady progress we all desire, the proportion of patients in the early stages of psychosis that started treatment within the two-week target was lower in January than it was in May 2016. In the first 10 months of 2017-18, 9.1% fewer patients started EIP treatment within the two-week target, compared with the first 10 months of 2016-17.

Behind those figures, as other hon. Members have indicated, are real people who are suffering the early manifestations of psychosis, which can be extremely disturbing for them and for their friends and family. I have had the privilege of visiting a number of in-patient units, not just in my constituency but across the country, and I have heard first hand about patients’ experiences. The longer they have to wait, the greater the negative impact can be on their condition and on their chance of recovery.

The Royal College of Psychiatrists points out that if people do not receive help early enough, they are more likely to experience poor physical health, lower levels of social functioning, and poorer occupational and educational outcomes. That is a serious concern for us all, which is why we are here this afternoon.

We also have to think about what happens in the future. I am grateful to YoungMinds for its analysis of the sustainability and transformation partnerships, due out next month, which shows that less than a quarter of STP plans demonstrate an explicit commitment and clear plan to meet the EIP target for 2020-21. It is not just about what has happened in the past and looking at the results retrospectively, but about what will happen in the coming years. The Government have endeavoured to have STPs, and the EIP target should be at the heart of what they are doing. Unfortunately, it is not, despite the fact that the implementation of that waiting time target is one of the nine requirements for STPs, as set out in the NHS planning guidance.

I will turn to an area that is of particular interest to me. In the year since the birth of my child, I have been even more aware of the need to support the mental health of new mums. Around 85% of new mothers experience some change in their mood, and for around 10% to 15% of them, that might mean more serious symptoms of anxiety and depression. More than 1,400 women experience post-partum psychosis each year in the UK, which is between 1 and 2 in every 1,000 mothers. I was struck that a woman is between 30% and 40% more likely to experience a period of psychosis in the year after childbirth—more than at any other point in her life.

Post-partum psychosis can take many forms, including hallucinations, depression, delusions and mania. It can be extremely distressing for mothers, their partners, their wider families, and of course, the child. I have had the opportunity to visit two mother and baby units across the country to hear from mums first hand. The condition does not discriminate. It can affect women of any background, colour and income, and it can have serious and far-reaching consequences.

The National Childbirth Trust, the Maternal Mental Health Alliance and others have specifically highlighted the paucity of provision of mental health services for new mothers and the effectiveness of the six-week check in identifying the early stages of mental ill health, including psychosis. In the mix of the debate, I hope the Minister will be able to comment on that.

[Dr Paul Williams]

I, too, have read the National Childbirth Trust’s report, “The Hidden Half”. It says that despite it being a vulnerable time for women, more than half of women who experience post-natal mental health problems say that they were not asked about them by any health professional. Will my hon. Friend join me in calling for that to be added to the GP contract so that GPs routinely provide a six-week check for the mother, as part of the six-week check for the baby?

[Luciana Berger]

I thank my hon. Friend for raising that important report and the campaign, which I have considered as well. The National Childbirth Trust makes an important point about the connection that GPs have with new mums and their babies. I recall that my GP did ask me about my mental wellbeing and how I felt, but that is not the case for every mum. It is something that we should consider, along with ensuring that every contact counts when it comes to new mums and their babies—be that with the health visitor, a midwife who might come to the home or someone in the hospital. We need to look at the whole spectrum of engagement to ensure that we consider the mental health of mum and baby every step of the way.

I mentioned mother and baby units, which are incredibly important. For anyone who does not know, they are an opportunity to ensure that if the mum is experiencing a period of psychosis or another serious mental illness, they are still able to be with their child. The units offer extremely specialised care and incredible attention from clinicians, who do a remarkable job of ensuring attachment so that mums are not disconnected from their babies, even if they have to be moved across the country.

Mother and baby units are very important for recovery rates. I have asked several parliamentary questions about them, but I want to ask more in the context of this debate because of their importance to mums who experience post-partum psychosis. In January, I asked the Secretary of State, in a written question,

“how many mother and baby beds commissioned by NHS England Specialised Services in 2016/17 are (a) available and (b) in use.”

I asked that because although we know that beds have been commissioned, it is not clear whether they are available or in use. The figures that I received in response to a previous question showed a decrease of one in the number of beds available across the country since 2010. I ask the Minister the same question again, publicly, because her response in January was:

“The information requested is not available.”

I do not think that it is a difficult question to answer. In the context of this debate, it is a very important one, so I hope the Minister’s officials will provide her with an answer today. Post-partum psychosis, no less than any other kind, requires early identification and early intervention, but we are not doing enough to treat or support post-partum psychosis alongside other forms.

Let me conclude with some brief questions that I hope the Minister will address. First, what steps is her Department taking to address mental health inequalities and the waiting times postcode lottery, particularly in cases of early episodes of psychosis?

Secondly, how can the Minister guarantee that money allocated for mental health services is actually reaching the frontline in all the areas in which it is needed? There are many examples of mental health budgets being raided to pay for other parts of the NHS.

Thirdly, does the Minister agree with the Royal College of Psychiatrists that we need to improve the financial data available for early intervention in psychosis services? Without it, we cannot be sure that services are properly investing in EIP.

Fourthly, does the Minister believe that frontline mental health services have adequate numbers of staff—including psychiatrists, mental health nurses and therapists—to meet the targets set out in the five year forward view? I echo the praise of other hon. Members for our frontline clinicians, who do an incredible job under very challenging circumstances but are severely stretched, as we hear time and again. They cannot meet the workforce challenge alone.

Lastly, what steps will the Minister take to drastically improve early intervention in cases of post-partum psychosis, especially at the six-week check for new mothers, so that we can support women in the first weeks after the birth of their baby?

I congratulate the right hon. Member for North Norfolk again on securing the debate. Let us hope that our deliberations this afternoon will lead to concrete improvements and swift action from the Government to prevent unnecessary psychosis, intervene early to prevent unnecessary suffering, and help as many people as possible across the country towards a meaningful path to recovery.