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We all know that mental ill health cannot be tackled by NHS mental health services alone. It is crucial that others-we have already heard about them this evening: local authorities, employment, housing, and criminal justice-play their part. The new health and well-being boards will be vital in helping local government, the NHS and others, including the voluntary sector, to tackle the causes of ill health at source. I look forward to seeing well-being services set up, which would include occupational health, housing, smoking cessation, fitness centres and mental health services working together for new attitudes towards public mental health.
Like others, I mentioned the importance of IAPT at the beginning of my speech, and I recognise that we have already heard some differing views on this tonight. While I am a great supporter of the concept of talking therapies, my view is that the current policy does not adequately or accurately reflect the importance of providing a range and choice of counselling and
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However, specialist providers, particularly those in the voluntary sector, have found it very difficult to navigate their way through an IAPT commissioning process that was clearly designed with the statutory sector in mind-a point that I thought was made very compellingly by the noble Lord, Lord Wills. I believe that counselling and psychotherapy play a vital role in promoting good mental health and well-being, and in the treatment of mental ill health. In my view, current government policy still does not sufficiently reflect the role that counselling and therapy can and do play. I would like to see more collaboration and joint working in this area.
Finally, I draw attention to the importance of improved mental health services for children and young people, for if mental health services have long been seen as the Cinderella of health services generally, surely children's mental health services are the Cinderella of that Cinderella service. Yes, the role of the NHS is crucial here, but so too is the role of schools and the voluntary sector.
We all know of the parlous state of the NHS Child and Adolescent Mental Health Services, known as CAMHS. In a recent survey of providers and commissioners conducted by YoungMinds, over half of respondents said that they intended to reduce their spend this year. The biggest cuts were in local authorities, with some slashing up to 25% from their budgets. On a more positive note, some 20% said that they were planning to increase their funding for CAMHS. All this can only exacerbate the existing, very large variations in availability, quality and timely access to these vital services. On top of these, many voluntary sector services, as we have already heard, are having to cut back or close down.
I welcome the new bond initiative funded by the Department for Education to increase the availability, quality and young-person focus of early intervention services that address mental health issues earlier. However, this is currently a limited pilot in five local authority areas. Equally, I welcome the new children's IAPT pilot, again in a small number of areas. I ask the Minister what plans the Government have for rolling this out more widely.
Touching on a point made by the noble Baroness, Lady Meacher, while thousands of young people in Wales and Northern Ireland benefit from national programmes of school-based counselling, England lags behind as the only country without a commitment to these services. This leaves many young people in England without effective and accessible therapeutic support in schools, despite the fact that counselling is associated with significant reductions in psychological stress. The Welsh Government's national school-based strategy, which has been externally validated, has been shown to be an overwhelming success, so much so that the Welsh Government are planning to make counselling in Welsh secondary schools a statutory service. With the clear benefits that it has demonstrated in improving
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Why have I made such a great play of children and young people's services? Research has shown that huge costs to the economy are associated with mental health problems, which all too often begin in childhood and continue into adulthood. Perhaps I may give noble Lords a few facts. Half of all lifetime mental illness presents by the age of 14, contributing to the vast economic and social costs of mental health problems. One in 10 children under the age of 15 has a diagnosable mental health disorder. Rates of mental health problems among children increase as they reach adolescence. Between one in 12 and one in 15 children and young people deliberately self-harms. More than half of all adults with mental health problems were diagnosed in childhood, but-this is the crux of the matter-fewer than half were treated appropriately at the time. According to the then Department for Children, Schools and Families in 2009, 60% of children in care have some form of mental health disorder. This is an astonishing figure that calls for an urgent response.
In summary, mental health problems obstruct many key goals for children. I would welcome the Minister saying what more the Government are doing to join up policy effectively, particularly between the Department of Health and the Department for Education, in order to address the mental health problems of children and young people. It is a no brainer that we must do this. It makes sense socially, economically and morally.
Baroness Young of Hornsey: My Lords, like other noble Lords, I thank the noble Lord, Lord Alderdice, for introducing the debate this evening. I am sure that we will all acknowledge that although some progress has been made in this area, there is still an awful lot of work to be done. No doubt we will return to this subject in the years to come.
I am very glad that the noble Baroness, Lady Tyler of Enfield, spoke so much about children and young people. This is a point that I, too, will make. She also raised the issue of the implementation framework for the mental health strategy for England. That is another area I will touch on this evening. As the noble Baroness stated, we need to do much more to build good mental health and resilience among children and young people from birth through to adulthood. At the other end of the scale we also need to address the challenges faced by an ageing population, with an increasing number of older people experiencing significant mental health problems, including but not exclusively dementia. As always, I am afraid that there is still a substantial job of work to be done to ensure that ethnic minority service users are treated fairly.
The content of the implementation framework has been well received. However, there is no statutory backing, and it is phrased only in terms of what local health and other bodies, including the voluntary sector, "might" rather than "must" do. At this time of severe spending constraints in the NHS, will the Minister explain how his department intends to ensure, first,
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An increasing body of evidence shows that children and young people can develop mental health problems from a very early age, and that these problems, if not addressed quickly, and effectively, have a higher risk of developing into adult mental illness. Most adolescent and adult mental illnesses can be traced back to childhood. Therefore, there is an urgent need to focus on children's early years, for example through building parenting skills and providing support to vulnerable families with young children. In addition, schools have a crucial role to play in building children's emotional well-being, especially given the link between mental health and academic achievement.
Although for clear reasons we focus on mental ill health, we should also look at how we understand mental well-being and how we can encourage and develop and make sure that that works, in order to pre-empt instances of mental ill health. I would like the Minister to acknowledge the importance of children's and young people's mental health, and outline the department's proposals for increasing support for parents and families, particularly with young children, in vulnerable situations. I reiterate what the noble Baroness, Lady Tyler, said about children in care being at very high risk of developing mental ill health both while they are in care and subsequently.
The Mental Health Foundation project, Age Well, is a two-year inquiry funded by the Esmée Fairbairn Foundation. We have been looking at the factors affecting the mental health and well-being of the generation of people currently aged between 55 and 65-the so-called baby boomers-as they get older. I have been privileged to chair the panel of inquiry that will be publishing its report on this subject shortly. The rationale for conducting the inquiry was that people born between 1946 and 1955 are now growing older and moving into a life-transition period. Growing older, of course, brings challenges that are different from those faced in earlier phases of life.
Evidence shows that the experience of mental illness in later life is often underrecognised, underrated and inadequately treated. Risk factors for mental ill health for the cohort include bereavement, the disabling effects of chronic conditions, pain, the effects of being a carer, loneliness, social isolation and so on. Protective factors include-and this relates to mental well-being-social ties, connectedness, intimate relationships, friendship and engagement in social activities. Good self-esteem and self-reliance can also buffer people against difficulties.
A major factor in population ageing is survival against premature death; fewer people in the 1946-1955 group have died in childhood, young adulthood or middle age, but the evidence is that they may not be much healthier than previous age cohorts as they grow older. Inequalities have been growing in the UK population since the 1980s. This is shown in a range of outcomes, including experience of illness and poor mental health.
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These are some of the key findings that we have uncovered and had witnesses speak to us about so far. We would like to be assured that the Minister and his department are fully aware of and are equipped to deal with the implications for our ageing population of mental ill health and promoting mental well-being.
The Mental Health Foundation and Age UK hosted an expert seminar earlier this year on mental health among older people. There were a number of key messages from that group. I am not going to go into them all now because there is a report available. However, there is no doubt that the NHS reforms have created a period of great uncertainty and that everyone interested in older people's mental health needs to keep pressure on the reorganised NHS, public health and local authority bodies to work together to plan and commission a suitable range of support for older people.
Another crucial issue for the mental health services must be ethnic minorities' experience of the mental health system; people of African Caribbean descent in particular are still being prescribed stronger medication, are more likely to sectioned, and, at least in London, are more likely to be referred to the mental health services by the police. Can the Minister tell the House about specific mechanisms for engaging with this issue and when we might expect to see some improvement in an area that has long dogged the mental health services?
Baroness Emerton: My Lords, I, too, thank the noble Lord, Lord Alderdice, for raising this important debate. Yesterday morning I was listening to Radio 4 and was somewhat taken aback when they said it was mental health week. A church service was being relayed from Epsom, I think, where there had been a great cluster of psychiatric hospitals. I really did not know that there was such a thing as mental health week, so I confess my ignorance. The Government had a No Health Without Mental Health strategy. I would add, no health without mental health, patient well-being, public health and physical health; in other words, a holistic care pathway.
I am a retired nurse and also a mental health carer. I concur wholeheartedly with the other speakers, particularly the noble Lords, Lord Alderdice and Lord Layard, about the benefits of psychological treatment and also how scarce it is. I say that with very definite first-hand knowledge-the scarcity is having an effect on the person I care for.
Much has been achieved in the provision of mental health services, but against the current situation of economic austerity and consequential cutbacks we are seeing areas where services are definitely suffering. I can give an example. Recruitment to mental health care nursing programmes is excellent, but the cutbacks in student numbers will have a long-term effect on people's readiness to come into nursing as registered nurses. Already the CQC has recorded that the situation has led to an increase in support workers to fill the gaps left by registered nurses. This is a false economy as the evidence is clear that if the ratio of registered
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Implementing the holistic care approach will be assisted by the Nursing and Midwifery Council. The care standards it is introducing are to be implemented in November this year in all universities preparing nursing students in all specialties to gain 50% theory and practice in each. This is further assisted by the Chief Nursing Officer's recently published vision of developing a culture of compassionate care. The values and behaviours of the vision are that at its heart are what are described as the "Six Cs"-compassion, care, competence, communication, courage and commitment.
However, as has already been mentioned by several speakers, there are still many barriers between the different professional groups: the NHS, local authorities, the third sector and the independent sector; they all need to be broken down. This requires a special kind of leadership that can effect change through not only a detailed knowledge of each organisation and how it works, but also the personal leadership qualities of persuasion and influence. This needs to be recognised within a defined government strategy with a given time-span. When the large psychiatric and mentally handicapped, as they were then, learning disability institutions were closed, there was a clear strategy with a timetable to address the situation. Many speakers have referred to the outcome framework, and surely something could be built into it. That would provide a definite target date for working towards a cohesive service and, in turn, it would allow for the development of the holistic care pathway.
Mental health services present a complex field of practice with an enormous plurality of providers and stakeholders. Added to this are the demographic profile of an ageing population and workforce, and a loss of experienced practitioners due to the financial cutbacks. Against this background, commissioners of services call for strong leadership that understands the complexity of conditions and has the sensitivity to know that providers are equipped to deliver high quality services. Would the noble Earl consider that there might be an opportunity for the Government to highlight the need for such leadership qualities and build this into the policy requirements? In the absence of high quality leadership, the culture of mental health services will deteriorate, leading to a fall in the quality of practitioners and the services provided, along with a lowering of standards. Can Her Majesty's Government allow that to happen to this very vulnerable group of the population? I think not.
Lord Patel of Bradford: My Lords, I too add my thanks to the noble Lord, Lord Alderdice, for tabling this important and timely debate. The noble Lord has made and continues to make an immense and important
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The question before us today is how do the Government intend to strengthen the provision of mental health services in the NHS? It is a vital question at a time when the NHS is facing the most significant upheaval in its entire history and the finite resources we have for healthcare are being further reduced.
When the coalition Government first came to power I was very pleased to see mental health given priority attention. Those earlier efforts to raise the profile of mental health problems were very much welcomed, in particular their strategy No Health Without Mental Health, although I think I prefer the title of the noble Baroness, Lady Emerton. The Government have continued to invest in talking therapies and we have seen the excellent anti-stigma campaign Time to Change. However, I have to ask myself what is really changing? What lies beneath all the rhetoric and good intentions? The problems are certainly not getting any less.
My noble friend Lord Layard talked about his recent report published by the London School of Economics that sets out some of the starkest evidence that I have seen that the problems are getting worse. More significantly, as we see increasing levels of problems, we do not see a similar rise in treatment services. The report clearly outlined that mental illness is now nearly half of all ill health suffered by people under 65 and it is more disabling that most chronic physical disease. Yet, only a quarter of those involved are in any form of treatment. Mental illness also accounts for 23% of the total burden of disease. Yet, despite the existence of cost-effective treatments, it receives only 13% of NHS health expenditure.
There are currently six million people with depression or crippling anxiety conditions, and more than 700,000 children with problem behaviours, anxiety or depression. The noble Baronesses, Lady Tyler and Lady Young, raised the important issues with respect to these children. However, most of these people receive no treatment because, as the report says:
It is a shocking form of discrimination because effective psychological treatments exist but are still not widely enough available. What steps are the Government taking to address this health inequality and to ensure that local authority and NHS commissioners do commission mental health services in line with NICE recommendations?
It is very clear that we cannot allow this situation to continue. At a time when the economy continues to struggle it is vital that these issues are addressed, because the lack of adequate mental health provision is threatening the chances of our economy recovering. For example, recent research shows that one in 10 workers has taken time off work because of depression. The MORI poll that identified this figure was conducted
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Notwithstanding the comments made by the noble Lord, Lord Alderdice, about therapies, evidence has shown that the cost of psychological therapy is low and recovery rates are high. Expenditure on psychological therapies for the most common mental health problems is also cost effective as long as we take heed of the comments made by the noble Baronesses, Lady Meacher and Lady Tyler, about the need for consistency, quality and choice of services. For example, when people with physical symptoms receive psychological therapies, the average improvement in physical symptoms is so great that the resulting savings on NHS physical care would outweigh the cost of psychological therapy-a point made clearly by my noble friend Lord Layard.
It was for these reasons that the Labour Government started in 2008 the six-year IAPT programme. We know that in areas where this has been effectively commissioned, it has had a positive impact. However, we also know that the £400 million earmarked by the coalition Government for psychological therapy has not always been used for its intended purpose because there was no commitment on NHS commissioning managers to do so. It is essential that that programme is completed as planned, since even this will provide for only 15% of need.
What about those with more complex and enduring mental health problems? Let us not forget that when we are talking about strengthening NHS services, this includes services provided in prisons, where we know there are very high numbers of people with mental health and substance misuse problems. In fact, the annual report to Ministers by the independent monitoring board at HMP Pentonville reported that health and social care workers providing health support to inmates are being stretched by a "serious and sharply increasing" rise in demand for care. The report stated that mental health teams at the prison received 24 referrals a week in 2011-12, up from 18 a week the year before. Incidents of self-harm had also increased "very significantly" over the past year. The prison's 22 in-patient beds, the majority of which are used for mental health patients, were full to capacity. The report said that the reasons behind the spike in mental health demand at the prison were "not fully understood", and warned that,
When we are talking about vulnerable groups, we know that people from black and minority ethnic communities face specific difficulties, including higher rates of mental illness in some groups and problems with access to the right care and treatment-issues raised by the noble Baroness, Lady Young. Service user groups have expressed fears that funding provided
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I share these concerns especially in light of the establishment of more generic service user involvement mechanisms such as Healthwatch England and local Healthwatch organisations. These cannot and must not be seen as a replacement for involvement mechanisms especially for mental health service users, and especially not for those that engage black and minority ethnic communities and have a rights-based focus capable of addressing issues in relation to the use of compulsion under mental health law. What specific steps are the Government taking to ensure that vital local user-led mental health groups are being maintained alongside Healthwatch and not being replaced by them?
In conclusion, it has been said that the challenge of mental health should be placed at the heart of Government but I suggest that where it really needs to be is at the heart of the new commissioning structures within clinical commissioning groups and local authorities. But as the NHS has clearly failed to commission mental health services in line with official guidance, and with further pressures to come on the whole NHS budget, will commissioners be able to take the action that is needed on securing and developing mental health services? I greatly fear that mental health services will continue to be the Cinderella services and that the urgency of need and the benefits that can be realised are not fully understood within these new and as yet untested commissioning structures. My final question to the Minister is: what will the Government do to ensure that clinical commissioning groups and local authorities address the full range of needs for mental healthcare in their commissioning plans?
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
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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-
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
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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.
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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
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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,
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