The Minister for Community and Social Care (Alistair Burt)
We have been fortunate in having rather longer than we normally get for an Adjournment debate, and that has allowed the right hon. Gentleman to speak at greater length about some of the issues affecting the historical imbalance between mental and physical health, with particular emphasis on out-of-area mental health placements. I congratulate him on securing this debate, and I am delighted to respond to it.
I thank other hon. Members who have contributed to this debate, including the hon. Member for Ceredigion (Mr Williams), the right hon. Member for Carshalton and Wallington (Tom Brake), and my hon. Friends the Members for Torbay (Kevin Foster), and for North West Norfolk (Mr Bellingham). My hon. Friend the Member for Halesowen and Rowley Regis (James Morris), who chairs the all-party group on mental health, has dropped in as part of his responsibilities in the House, which I welcome. I also welcome the Whip, my hon. Friend the Member for Truro and Falmouth (Sarah Newton).
Before I come on to respond in more detail, let me make one or two general remarks. The right hon. Gentleman referred right at the beginning to the long-standing nature of some of these problems. These issues have not arisen in the past six months. They have been here—Government in, Government out—for some time. The coalition Government made huge strides in recognising the importance of mental health and drove forward some of the changes that needed to be made. It is certainly clear that part of my responsibilities now is to pick up on that and to build on it.
If I may just make reference to the right hon. Gentleman for a moment, I think his key achievements include: the expansion of psychological therapies; the reduction in the use of police cells for people experiencing a mental health crisis; introducing the first access and waiting time standards; and piloting the sense that there has to be parity of esteem. Those achievements absolutely underpinned what I came in to find in the Department. The intractable nature—or at least intractable up to now—of some of the problems has been graphically illustrated by the right hon. Gentleman’s passionate expression today of some of the things he was not able to do during his time as Minister. They set the baseline for what I hope to do. He asked for a personal commitment to drive forward the changes. Absolutely. The bar has been set quite high.
As the right hon. Gentleman and others have mentioned, what has puzzled me most since being in office is the variability of practice. How is it that in two areas side by side with exactly the same resources there will be one that has a set of procedures in place to ensure that good treatment is provided, while in another that is not the case? It is not always about resources, but management and leadership. I have been puzzled by why there is so much variability.
There is another puzzle that is very pertinent to what we are talking about today and to which the right hon. Gentleman referred: the perverse incentives in the system. Treatment costs are split between local authorities and the NHS. They seem to be based not on what is in the best interests of the patient, but on what suits the budget best. Now, none of us are naive. We all know this goes on. However, his description of the letter from his constituent, which I know about because I responded to him about it this week, illustrates the impact on the individual of decisions that people make for perverse incentive reasons—perhaps relating to budget, if that was one of the reasons. I am interested, as he is, in why there is such variability between areas. Some areas seem to have very few out-of-area places and others do not.
I hope to be able to deal with all the right hon. Gentleman’s questions, but before I do I want to put a few points on the record. The Government’s commitment is clear. We have given the NHS more money than ever before for mental health, with an increase to £11.7 billion last year. We have made it clear that local NHS services must follow our lead by increasing the amount they spend on mental health and making sure beds are always available. In the spending review and autumn statement, we announced an additional £600 million for mental health over the next five years to increase psychological therapies, crisis care and perinatal mental health. This reaffirms our commitment to achieving parity of esteem for mental and physical health.
In perinatal mental health services, for example, I want to ensure that women are able to access the right care at the right time, and close to home. I know that provision of specialist perinatal mental health services varies across the country. Some women have access to excellent care and support, while there are serious gaps in provision in other areas. Women suffering the most severe and complex perinatal mental illnesses need access to specialist in-patient mother and baby units, and good quality community support care in the area where they live. There are currently 15 units in England—I understand that the number fell by a couple from between 2010 and 2015—but NICE estimates there is a UK shortfall of between 60 to 80 mother and baby unit beds. That is why we announced in the March Budget that the Government would invest an additional £75 million over the next five years, £15 million a year, to support women suffering from mental ill health in the perinatal period. NHS England is leading a work programme to ensure that this extra money is spent in the right way at the right time and in the right places. The right hon. Gentleman’s work has made that base. I give him as much assurance as I can that in the areas where he set the work in progress, that work is going to continue; in places where the work is going slowly, it will be challenged; and in places where he was not able to make the progress he wanted to make, I set myself the challenge to do just that. I do not have to worry an awful lot about freedom of information requests because I will get the questions from him and from a number of hon. Friends and colleagues who have grasped how important this issue is.
Let me return to the source of the debate. I greatly appreciate the work that the right hon. Gentleman put in train earlier in the year with NHS England and mental health provider organisations to understand the pressures that lead to people being sent away from home for treatment that should be available locally. This has helped to provide a picture of the scale of the problem and to raise its profile. We know that the principle should always be for care close to home in the least restrictive setting. It is not acceptable for people to be travelling for miles when they are acutely unwell.
I know about the case that the right hon. Gentleman raised because I dealt with it this week, and I agree with him that some of the attitudes expressed by some of those responsible for people’s care are just not good enough. It cannot be acceptable and it cannot have been acceptable to listen too little to those who are in care or who are being cared for when they have made complaints about treatment. I am well aware of the problem—I am occasionally chased on Twitter about it—and I say to one or two of the groups that I am looking carefully at how to deal with it better. Sometimes people feel that they have not been listened to, and I suspect that the sort of example revealed in the right hon. Gentleman’s constituent’s letter might be rather more common than we think. Accordingly, I want to ensure that the inspection and regulation regime really picks things up. I know that there will sometimes be differences in opinion and that things will need to be clarified, but I do worry about the attitudes sometimes expressed, and I want to make sure that the Department has really got hold of ensuring that those sort of complaints are picked up and, whenever possible, really burrowed into to find out what might have gone on.
Norman Lamb
I appreciate the Minister’s reassurance. One of the issues highlighted in my constituent’s case was the fact that he was transported very late at night, arriving at about 1 am, and there was another person from Norfolk in the same unit that same week who was collected at 1 am from the unit to be brought back to Norfolk. This treats people like chattel; it does not treat them as human beings. Is the Minister prepared to highlight to the Care Quality Commission that it should investigate and explore that particular aspect—the transporting of people—because having to travel in a minibus with someone who does not talk to them for three hours, and arriving very late at night is simply outrageous?
Alistair Burt
Of course it is, and I share the right hon. Gentleman’s frustration. I write a lot of letters to colleagues who express concerns and I have to signpost them to the other organisations in the health sector that have responsibility for taking particular decisions. That is quite right, because local decisions ought to be local. Clinical commissioning groups or trusts need to be responsible and accountable for what they are doing. However, I have to tell the right hon. Gentleman that it is occasionally frustrating when I feel that I cannot pick up the phone and make my own inquiry. We cannot run a system in which Ministers arbitrarily pick up cases because they are the ones we know about; there has to be a structured system. When particular things come to light, I am looking at how to use my position and the authority of the Department to make sure that something has been properly gone into—even if it is somebody else’s statutory responsibility. We in this House who remain accountable for things should be able to make sure that those statutory groups, including the CCGs, have really got a grip. I am keen to pursue that.
Mr Bellingham
Does the Minister agree that there is something fundamentally unsatisfactory—and, indeed, wrong—about moving someone late at night unless it is absolutely necessary for medical and clinical reasons?
Alistair Burt
Yes. It seems very puzzling that that should be a regular practice, if it is. That should not be the case. Of course there are all sorts of different pressures on the system, and it would probably not be appropriate to say that it should never happen, but, in principle, people who are in a state of anxiety should be moved with the maximum care, at the time that is of greatest benefit to them and their health needs.
As I was saying, it is not acceptable for people to be travelling for miles when they are acutely unwell. It is also not acceptable for staff to be spending time phoning around to find beds for their patients.
Let me return briefly to the impact of social media. A couple of weeks ago, I read in a tweet from a frustrated doctor—I hope he will pick up on today’s debate—that on that particular day no bed had been available for a woman anywhere in England. Along with the hon. Member for Liverpool, Wavertree (Luciana Berger), who had raised the matter with me, I made inquiries and found that that was not technically true; beds were available. The response from the doctor was, “You may be technically correct, Minister, but it is very difficult to find them”, and the results of my inquiries suggest that that is true. We need to establish a better system of identifying beds that may be available, because that too is part of the problem. People should not be spending time looking for beds. I have an idea about that, which I shall mention later in my speech.
I had to tell the clinician that I did not think that, technically, what he had said was true. However, I recognise that for those who are in the business of finding beds for people, it should not be as difficult as it appears to be, and I want to establish what we can do to help.
We know that the need to place people out of area, away from home, family, friends and networks, is a “warning sign” of a mental health system that is under pressure, and we know that no one wants to spend scarce resources on sending people out of area. However, we cannot look at out-of-area treatments in isolation, because they are part of the mental health acute care pathway as a whole. I welcome the interim report of Nigel Crisp’s commission, which was set up to review the provision of acute in-patient psychiatric care for adults, and I look forward to reading his final report and recommendations early in the new year.
Lord Crisp’s interim report made it clear that—as I am sure the right hon. Member for North Norfolk knows—the situation is more complex than a shortage of beds. We know that there has been a long-term reduction in the number of psychiatric beds in England, but the report suggests that in many areas there would be enough beds if improvements were made to other parts of the system and integrated, community-based services were commissioned. That very point has been made this afternoon in relation to the variability of practice. The report also made it clear that the so-called bed crisis, or admissions crisis, is a problem of discharges and alternatives to admission, and can be dealt with only through changes in services and in the management of the whole system.
As the right hon. Gentleman pointed out, that can be done, as has been demonstrated in a number of local areas. Sheffield, for example, has almost entirely eliminated adult acute out-of-area treatments, and has reduced average bed occupancy to 75% by redesigning the local system, That has included investing in intensive community treatment, and working in partnership with housing. In the right hon. Gentleman’s own constituency, Norfolk and Suffolk NHS Foundation Trust has begun to reduce its historical problem of out-of-area treatments through a combination of investing in more acute adult beds and working with commissioners to develop community and crisis resolution services.
I understand that the independent Mental Health Taskforce has spent some time discussing these issues. I hope that its report, which will be published in the new year, will be an important driver for improving mental health services over the next five years, and will address many of the key issues raised in Lord Crisp’s interim report.
Norman Lamb
Can the Minister confirm the likely publication date of the taskforce’s report? I think he said it would be in the new year, but can he give me his best estimate of a specific date? Also, I would like to acknowledge that the Norfolk and Suffolk NHS Foundation Trust has made real progress. The number of people being sent out of area has come down significantly, and that needs to be recognised.
Alistair Burt
I am grateful for the right hon. Gentleman’s comment about his trust. My understanding is that the taskforce’s report will come through very shortly. I am not sure whether it will be done this month or by the start of next month, but it is imminent.
I appreciated the right hon. Gentleman’s kind remarks about the Secretary of State for Health. The Secretary of State has already agreed an action plan to tackle out-of-area treatments for adult acute in-patient care. Where out-of-area treatments are a problem, local areas will be asked to put in place clear action plans demonstrating how they can reduce out-of-area treatments, in the best interests of patients, during the course of 2016-17. Now I come to one of the right hon. Gentleman’s challenges. Building on this, I intend to go further and put in place a national ambition to address out-of-area treatments. I will do this in consideration of the Crisp commission and the taskforce report, and I will communicate details of this ambition by the end of March 2016—that is, by the start of the next financial year.
I want to wait and see what Lord Crisp and the Mental Health Taskforce say and then consider exactly what the ambition should be. Should it be an ambition for complete elimination? Should it provide a much tighter variation? I want to see those reports before I set the ambition, but I will set it, and the targets, and come back to the right hon. Gentleman and the House before the end of March next year to communicate those decisions. I hope that helps.
I also commend the right hon. Gentleman for recognising the need to improve mental health crisis care and for launching the mental health crisis care concordat, which we have discussed today. This debate has given us an opportunity to talk about variation in practice, the quality of street triage and the fact that we can do different things in different areas. I saw the work being done in Bradford, for example, where the mental health practitioner is located in the control room, as opposed to being on the street. The galvanising of local groups to work together by giving them the responsibility of doing the job has been absolutely vital. The way in which we are reducing the number of people detained in police cells is a clear example of how that process is working.
The Government are equally committed to reducing out-of-area mental health treatment for children and young people. In-patient child and adolescent mental health services—CAMHS—admission is a relative rare event. At any one time, however, there are approximately 1,300 children and young people from England in CAMHS in-patient services. Services themselves are usually subdivided into different specialties, such as eating disorder units or low secure units. That means that it is highly challenging to provide complex care in all areas, and on occasion, some children and young people may need to be referred for specialist treatment at a distance from their home, if that is in the best interests of their care. However, we are committed to ensuring that that is as rare an event as possible, and much progress has already been made.
Norman Lamb
One of the recommendations from the taskforce that NHS England established to look at tier 4 services, at the number of beds required across the system and at the variability of the services was that treatment should always be contained within a region —in other words, that no child who lives in the south-west should ever go out of the south-west for treatment. I cannot remember where the child from Torbay had to go—
Norman Lamb
Indeed. Is the Minister going to stick to that? Is he going to ensure that that is the objective, and will he monitor it to ensure that he meets it?
Alistair Burt
As much as possible, absolutely, yes. There will be occasions when very specialised treatment has to be given, and that will on occasion be outside the area. But apart from that, absolutely. We want to provide care that is appropriate to people in a place that is closest to where they are, as much as possible.
In 2014, NHS England published the tier 4 CAMHS review. This found a relative shortages of beds in some regions, meaning that some children and young people had to travel long distances to access a bed, owing to an uneven distribution around the country. As the right hon. Gentleman knows, there was an immediate response to this: £7 million in additional funding, taking the total number of beds now to 1,440, the highest number there has ever been. In addition, NHS England has introduced new national protocols for referrals and discharge, and a new “live” bed monitoring system to make the best use of existing capacity. I am interested in whether that capacity has reference and relevance to the adult acute beds, and could it make the job of my friend the clinician doctor that bit easier?
But while these measures have helped in the short term, we want to build on this progress still further and ensure long-term, sustainable improvements. In January this year, NHS England commenced a comprehensive review of the procurement and commissioning of inpatient beds. The aim of this is to establish the long-term requirements for inpatient services and ensure quality, sustainable services are commissioned in the right place, based on population need.
It is not enough simply to provide more and more beds. In order to ensure that improvements are sustainable, we need to improve the community-based support we offer to children and young people. This is at the heart of the vision set out in “Future in mind”, and we are determined children and young people have easy access to the right support, from the right service, at the right time and as close to home as possible.
Key to achieving this vision are the local area transformation plans now being put in place. CCGs have been asked to work with NHS specialist commissioning teams responsible for inpatient services in the creation of these plans.
I have two final points. I have been interested in what data are available and what are not, and I answer a number of questions by saying, “The data for these are not collected centrally.” I am looking hard at each and every one of those questions, asking, “Are there occasions when we should be doing more on the data?” There is a lot still to do, but I entirely take the right hon. Gentleman’s point.
On data, we are looking at the limitations. The right hon. Gentleman was right to talk about the problems in getting this dataset right, but, again, I am on to that; it is essential, and I will take the challenge of driving and moving on that data.
On providers, the responsibility seems to come down to CCGs. It is unacceptable that private providers do not submit data. Some more have started submitting since the summer. It is the responsibility of CCGs, who have the contractual levers, and need to use them. That is not good enough; if we need this information, we need this information. I am going to look at whether the CCGs are using those contractual levers, and if not, why not. If they are not, and a sanction can be applied, we will apply the sanction. That information is necessary, and I am going to do this. The right hon. Gentleman is absolutely right on that.
On the principle in respect of determination, I will come back to the right hon. Gentleman by March next year and set out the national ambition. Do I commit to ending the practice completely? I do not know yet, because I want to get the result of the commission. It is right that it should be reduced to an absolute minimum. I want to know technically whether it is possible to eliminate it, or whether that would actually not do the job that is necessary. I want to see what the commission has to say.
Will I drive these changes? Yes, I will. Will all providers provide data? Yes, they will. Will I commit to the £1.25 billion? Yes, I will. I have said that enough times in enough places to make this a very difficult Government commitment to slip away from. It is over the course of the next five years, but I am happy to repeat that.
Norman Lamb
I am grateful to the Minister for his patience in allowing me to intervene again. I am conscious that there is a risk that the shortfall in the first year is made up in 2020 or something like that. Because of the principle of frontloading to invest in change, it would be incredibly helpful if we could get the commitment to make good the shortfall in 2016-17. Can he commit to doing that?
Alistair Burt
There are things I can do and things it is unwise to take a flyer on, standing at the Dispatch Box.
Alistair Burt
I will try, but we need to make sure all the money is used sensibly. There are a lot of pressures on the system, and I am trying to be as bold as I can without being foolishly bold and saying things just for the sake of it. I understand the importance of this £1.25 billion. I have spoken about it a great deal; I want to see it all used. I am not responsible entirely for the timescale, but I understand the right hon. Gentleman’s point and I suspect it will come up in the Opposition day debate we have next year.
I will talk to the Secretary of State about the right hon. Gentleman’s last point about comprehensive maximum waiting times. I will see where we can go further and include it in a comprehensive letter to the right hon. Gentleman.
I hope that this has been helpful. I am delighted that we had extra time to cover the ground. I am pleased to take up the challenge to do some of the things that could not be done in the past few years, and I will do my best to live up to the expectations of the House, as expressed by a number of Members today.
Question put and agreed to.