Health and Social Care Bill

Baroness Hollins Excerpts

Tuesday 25th October 2011 Lords Chamber

[Lord Newton of Braintree]

Monitor has extended responsibilities—and, importantly, a much clearer remit to be concerned with the quality of patient services—beyond what it had when its overwhelming focus was on financial matters. I regard that as an improvement. The Secretary of State under the Bill has more powers over Monitor than it had under the original proposals introduced and passed by the Labour Government. I see that the noble Lord, Lord Warner, is nodding his head.

This is a difficult and complex area. We could argue for ever about the best way to deal with it. I say to my noble friend on the Front Bench that I hope that we can find a way forward. I also hope that many noble Lords will recognise that some things said about the Bill are simply not true.

[Baroness Hollins]

My Lords, I seek clarification. I am very sympathetic to the amendment tabled by the noble Baroness, Lady Williams. To remove a key word without good reason causes anxiety and I am not convinced by the reason given for removing it. Perhaps I could ask the noble and learned Lord, Lord Mackay, to clarify whether his amendment would ensure that the obligations required as a result of the Coughlan case would still be protected.

[Lord Mackay of Clashfern]

Yes, precisely; I tried to say that when I referred to the 2006 Act. The passage in the 1946 Act on which my noble and learned friend Lord Woolf relied as Master of the Rolls in Coughlan was the first part—that is, the duty to promote a comprehensive health service, free at the point of need. That was its function. It was in the nature of a preamble: the first part of the first provision of the Act. That was what my noble and learned friend Lord Woolf regarded as enforceable. In relation to Amendment 1, I said that that section had been demonstrated to be enforceable in law, which one could not say for sure about the amendment that the noble Baroness, Lady Thornton, promoted as the first clause of this Bill. Of course, the provision referred to by my noble and learned friend Lord Woolf is maintained in the Bill.

NHS: Future Forum

Baroness Hollins Excerpts

Tuesday 14th June 2011 Lords Chamber

[Earl Howe]

The noble Lord, Lord Hunt, raises an important issue. I agree with him that the quality of general practice has been extremely variable. We saw a report the other day, published by one of the think tanks, which said exactly that. We have some very good GPs, but we have some who, frankly, are less than the standard that we would want and expect in primary care.

We are doing a lot of work to roll out leadership programmes for general practitioners. The National Leadership Council is working with GPs to agree the skills required for commissioning and will assist GPs in developing these skills as appropriate. The NHS institute is also doing some good work in this area and we will shortly be able to provide a bit more detail on how we can develop leadership, regionally and nationwide.

The noble Lord’s question runs rather wider than that, being about the quality of care delivered by GPs. In rolling out the outcomes framework and the commissioning outcomes framework, and the transparency that goes with that, it will become rapidly apparent which GPs require more support. I have no doubt that the consortia or, as we are now calling them, clinical commissioning groups will see it as being in their interests to ensure that the poorer performers are brought up to the standard of the best.

[Baroness Hollins]

My Lords, I commend the Government on the depth and breadth of the consultation that has taken place. I particularly welcome the new focus for Monitor on integration and the proposed coterminosity of the clinical commissioning groups with local authorities, which is particularly important in the case of commissioning integrated mental health and learning disability services. Does the Minister agree that the changes now proposed can be expected to meet better the needs of people with serious mental illness, learning disabilities and other complex needs than the Bill as originally published, and that the focus on health inequalities will allow the Secretary of State to monitor reductions in them for those vulnerable groups?

[Earl Howe]

I am very glad that the noble Baroness, with her considerable expertise, raised the important subject of serious mental illness and the needs of those who are particularly disadvantaged. She is right: we now have a much better way forward in commissioning services for those particularly difficult-to-care-for groups, if I may put it that way. How services will be commissioned for those with special needs and serious mental illness will, I think, emerge as we go forward. However, in my own mind I can see that local authorities and consortia may well decide to commission services jointly. There will be the means to do that through pooled budgets and shared arrangements. We will ensure that the quality premium, the details of which are still being worked through, genuinely rewards the ironing-out of health inequalities. We are absolutely clear that one of our goals is to address health inequalities at every level, and that includes in mental health.

Winterbourne View

Baroness Hollins Excerpts

Wednesday 8th June 2011 Lords Chamber

Asked By

[Baroness Hollins]

To ask Her Majesty’s Government, further to yesterday’s Written Ministerial Statement, whether they will ensure that the terms of reference of the serious case review into the abuse at Winterbourne View encompass the question of the appropriateness of placing people with learning disabilities in private hospitals.

[Baroness Hollins]

My Lords, I declare an interest as a psychiatrist who has spent much of the last 30 years working with people with learning disabilities who have similar needs to those of the subjects of the shocking “Panorama” programme. I am also the carer of an adult man who has a learning disability and whose behaviour at times challenges those who support him. I have also been a policy adviser on learning disability to the Department of Health on two occasions.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, the safety and quality of care of those with learning disabilities are of the highest importance. We will discuss the terms of reference for the serious case review with South Gloucestershire Council. We want to ensure that the terms of reference for all of the reviews by the local authority, the strategic health authorities and the Care Quality Commission will give us the evidence that we need to answer the serious questions raised by the events at Winterbourne View. We have asked Mark Goldring, the chief executive of Mencap, to work closely with us in reviewing the evidence.

[Baroness Hollins]

My Lords, I thank the Minister for his response. The national picture needs to be thought about. This matter is not happening just in south Gloucestershire. I understand that there may be as many as 150 private hospitals. I consider that to be unacceptable given the three decades of work to close NHS long-stay hospitals, which was finally achieved just two years ago. Will the Minister consider reversing the decision to end the employment of the national director for learning disabilities, who, as a policy adviser to the department, could have responsibility for overseeing the implementation of government guidance? The Mansell report gives guidance on how to manage and support people with learning disabilities and challenging behaviour in the community, rather than exporting them a long way from home to private hospitals.

[Earl Howe]

My Lords, I am grateful to the noble Baroness. She raises some important issues. I am aware that the chief executive designate of the National Health Service commissioning board and the current chief executive of the National Health Service, David Nicholson, will be looking at the whole question of national clinical directors and leadership in clinical care in the coming months.

The noble Baroness is right about care in the community. That has been the direction of travel under the previous Government, as it is now. She will know that many Winterbourne View residents were sectioned under the Mental Health Act and had challenging behaviour, an area I know she has experience of. I believe that privately provided care can be trusted; if the commissioning is right, if regulation is right and if the arrangements for oversight are right, it is not intrinsically less likely that privately provided care will be delivered at the right levels of quality.

Care Homes

Baroness Hollins Excerpts

Tuesday 7th June 2011 Lords Chamber

[Earl Howe]

My Lords, that is a rather harsh suggestion regarding Southern Cross. The noble Lord will know that care providers must demonstrate to the CQC that they have the financial resources needed to continue to provide services of the required quality. Clearly, there are lessons to be learnt from this episode with Southern Cross, which we all hope will resolve itself successfully. I am sure the CQC will take on board the lessons. From the briefing that I have had on the financial model that Southern Cross adopted, it is extraordinarily complex even for an expert to understand. We need to get that right. I know that my right honourable and honourable colleagues in the Department for Business, Innovation and Skills will be looking in general at business ownership and the issues surrounding that to see whether there are actions that we can take to prevent this kind of thing happening again.

[Baroness Hollins]

My Lords, with respect to Winterbourne View, could the Minister comment on why so much public money is being spent on placing people with learning disabilities in private hospitals, when government policy is to support such people in the community?

[Earl Howe]

My Lords, that falls a little way outside the Question on care homes and Southern Cross. I am sure the noble Baroness knows that Winterbourne View is a private hospital with completely different commissioning arrangements. However, I should be happy to write to her. A Written Ministerial Statement that sets out the full position on Winterbourne View is being put down in Hansard today.

Mental Health: Children in Local Authority Care

Baroness Hollins Excerpts

Monday 23rd May 2011 Lords Chamber

[Earl Howe]

My Lords, with his experience in this area, the noble Earl hits upon some extremely important points. As he will be aware, support for the mental health needs of looked-after children is at its most effective when child and adolescent mental health services, CAMHS, provide dedicated resources to work with looked-after children and their carers with trained and experienced staff. It is up to local authorities to decide the level at which staff should be appropriately deployed. Targeted CAMHS for looked-after children should work closely alongside the child’s social worker, carers and other professionals such as nurses and paediatricians. It is reassuring that data collected over past years for the CAMHS mapping survey by Durham University show an increase from 2003 to 2009 in the number of social services teams and teams with a focus on looked-after children, although those data carry a slight health warning in that participation in the survey, I understand, was voluntary.

[Baroness Hollins]

My Lords, how much research are the Government funding into the mental health and social outcomes for looked-after children and for adults who were looked after as children?

[Earl Howe]

My Lords, the noble Baroness may know that NICE and the Social Care Institute for Excellence prepared guidance recently on promoting the quality of life of looked-after children and young people. In doing so, they considered evidence including research reviews, a practice survey, a consultation with young people who have been in care, field work with practitioners and the testimony of expert witnesses. The evidence demonstrated that the health and well-being of looked-after children and young people are affected by nearly all aspects of their lives and care. The noble Baroness may like to know that a detailed list of that evidence is contained in appendix C to the guidance.

NHS: Standards of Care and Commissioning

Baroness Hollins Excerpts

Thursday 31st March 2011 Lords Chamber

[Baroness Hollins]

My Lords, I, too, am somewhat daunted about speaking about my interests in this debate in such a short time, but I am grateful for the opportunity. I note that the Care Quality Commission has just published its second annual report. Encouragingly, it talked about safer services and an upward trend in the standards of healthcare.

Noble Lords would expect me, as a former president of the Royal College of Psychiatrists, to speak about people with mental illness and learning disabilities. I shall do that but I will focus on the physical health of people in that group and their access to acute hospital services. That relates to commissioning. Although I do not think that commissioning is the key to all the problems in the NHS, strong commissioning is important. At the moment, commissioning largely does not understand the needs of people with learning disabilities and mental illness, particularly when their needs are complex and they are seeking care in an acute hospital setting. I shall try to explain what I mean and will give two examples.

If we stop to think about maternity services—my noble friend Lord Patel may have a different view—we find that the most complex kind of maternity case is a mother with a severe mental illness. However, the current tariff does not cover the mental illness that that mother has and the obstetric department does not have to purchase mental health services to look after that mother. That is a real shame, as this is a good moment in a woman’s life to attend to her mental health needs and the mental health needs of her child. That is just one example.

The Bill sets out clearly the kind of duties that commissioners will have in the future and suggests that commissioners will need to seek advice, but what kind of advice is not clear. GPs will need to work closely with their clinical colleagues in different specialisms, particularly specialists in mental health, to ensure that their patients with mental illness get their ordinary, everyday healthcare needs supported and adequately met, and not just their specialist needs.

People who do not work in psychiatry often think that commissioning for mental illness or learning disabilities is about buying specialist services somewhere else and that it has nothing to do with the rest of the health system. That is just not true. There is no health without mental health and I am pleased that the Government’s policy on public health acknowledges that.

Because I have less than a minute, I shall turn only briefly to learning disability. Tom Clarke MP spoke in the other place yesterday about the NHS and public satisfaction. He spoke extremely eloquently and, since I do not have time to repeat all that he said, I encourage noble Lords to read Hansard. He talked about the long history of concern of Mencap and other bodies about the institutional discrimination that has been found in the NHS—not a culture of care but a culture of discrimination. The previous Secretary of State established an independent inquiry into healthcare for people with learning disabilities. It came up with some important recommendations, including recommendations for training all healthcare professionals. I would appreciate support from the Minister for such recommendations to be fully implemented when the new Bill comes in.

Health: Mental Health Strategy

Baroness Hollins Excerpts

Monday 14th February 2011 Lords Chamber

[Baroness Hollins]

My Lords, I am grateful to my noble friend Lady Murphy for securing this debate, particularly as it is the first debate on mental health since my introduction in November. I, too, declare an interest. Although I began my medical career as a general practitioner, I have worked for probably 35 years as a psychiatrist, particularly working with people with learning disabilities and complex mental health problems.

As a former president of the Royal College of Psychiatrists, I am quite accustomed to arguing the corner for mental health. I remember writing to Gordon Brown when he was Prime Minister suggesting that when he spoke about health, it would be a good idea to use the phrase “physical and mental health”. When the word “health” is used, people, including doctors, tend to think about surgery and surgical interventions, but not about mental health. Gordon Brown and the rest of the ministerial team then referred to physical and mental health for about six weeks. I wondered why it did not last any longer and came to the conclusion that it was because of the difficulty in trying to understand the complexity of mental health problems, plus the discrimination associated with mental illness and the fear and ignorance which go along with that.

There was a time when cancer was spoken about in hushed tones. No one had the language or the confidence to speak openly about it. In many ways, mental illness today is where cancer was all those years ago. My vision is of a time when mental illness will be spoken about more openly by politicians, the public and medical professionals; when everyone has a language and the confidence to express what needs to be said and what needs to be done; and when people with mental illness and learning disabilities will be more fully accepted and included in society. I am delighted that these are the objectives of this excellent new mental health strategy, No Health without Mental Health. I applaud its public health focus and the determination expressed within it for parity of esteem.

At the end of my presidency in 2008, the Royal College of Psychiatrists launched its manifesto, A Fair Deal for Mental Health. At the time, the campaign pointed out that only 12 per cent of NHS spending was on mental health, a share that did not accurately reflect the human and economic cost of mental illness. I therefore welcome the recognition in this strategy that mental health problems cost England £105 billion every year and that these costs are incurred across several government departments, including health, education and criminal justice. The challenge will be to address the imbalance between investment in physical health services and investment in mental health services at this time of financial constraint.

The failure of commissioners and managers to make provision for the overlap between mental and physical conditions leads to expensive and unnecessary investigations, such as for medically unexplained symptoms, and for missed opportunities to treat, for example, depression associated with heart disease. People who are depressed are much more likely to die from heart disease even when their depression has been effectively treated. This points to an interrelationship between physical and mental health which is rather overlooked. I always say to medical students, “Have you noticed that the brain and the heart are in the same body?”. There is plenty to research in this interrelationship, but the separation between physical and mental health has not allowed us to look at it properly.

I did not see much mention of research funding in the strategy document, although I may have missed it, but research will be a critical friend in the move towards better mental health services. Here is the rub: for every £1,000 of charity funding for cancer research, just £26 is available for mental health research. The stigma associated with mental illness has a negative impact on charitable giving for mental health research. Mental Health Research UK, the first mental health research charity, is struggling to establish itself and would benefit from proper funding so that it can begin to be a significant player in the research arena. Government sources such as the National Institute for Health Research need to start giving priority to mental health research in order to redress the inequity.

Finally, I should like to comment on the provision of appropriate treatments for all patients with mental health problems. I welcome the proposed increased investment in the Increasing Access to Psychological Therapies project, in particular the expansion to engage with harder-to-reach groups, but I am concerned that there are still no plans to extend talking therapies to people with learning disabilities who, again as far as I can see, receive no mention in the strategy documentation.

The nuts and bolts of how to provide effective treatments for people with complex mental health needs, such as those with learning disabilities, are often poorly understood. Face-to-face appointments are clearly an essential component of treatment, but the specialised supervision, consultation and multidisciplinary liaison that is needed behind the scenes is expensive, although crucial to enable success. Highly specialist teamwork is the only way of both managing risk and enabling patients with complex needs to access appropriate treatments and reach better mental health outcomes. The pathway from primary care treatments for people with common mental disorders to specialist mental health services for those with complex problems needs to be commissioned carefully.

I know that the noble Earl and the rest of the health team are determined to improve the quality of mental health outcomes, but I seek assurances that established complex needs services for people with severe mental illnesses, including services for those with learning disabilities with a dual diagnosis of mental illness, will not be cut to pay for the new public mental health programmes.

NHS: Global Health

Baroness Hollins Excerpts

Monday 20th December 2010 Lords Chamber

[Baroness Hollins]

My Lords, I, too, welcome the initiative of my noble friend Lord Crisp in calling for this debate.

As a former VSO volunteer myself in Nigeria many years ago—an experience that I consider to have had a major influence on my career and outlook—I am keen to give more opportunities for healthcare professionals today to gain a better understanding of global health issues. I should like to discuss attempts to develop greater awareness of global mental health issues, particularly in postgraduate psychiatric training by the Royal College of Psychiatrists, and I declare an interest as a former president of the college.

With the help of Professor Rachel Jenkins of King’s College, a scheme called the college volunteer programme was established about five years ago. We had wanted to set up a programme with VSO, as two other colleges had done, but this was difficult because VSO responds to requests for volunteers and it was not receiving requests for psychiatrists. In a way, that indicates the low priority given to, or low recognition of, mental health issues in many of the countries where VSO works. Therefore, we set up our own programme and gained agreement to the principle of out-of-programme placements abroad, fully approved for higher training. We put in place some safeguards, which included an in-country mentor providing supervision of all placements, with supplementary e-mail supervision from a UK-based consultant who had relevant overseas experience and who would have helped to prepare the volunteer in advance.

The intention was threefold, as I shall set out, although not in any particular order. The first was to provide a training experience in global mental health for UK trainees so that they would better understand the health perspectives and needs of migrant communities here in the UK. The second was to do that through meeting an identified need in the host country in a sustainable way. Often such needs were identified through our own college members and fellows who live and work in low and middle-income countries around the world. The third was to ensure that trainees would be equipped and motivated to be able to contribute to health services in low and middle-income countries in the future.

A number of mental health trusts have set up a specific link with a country, and I give as an example the trust where I have an honorary consultant contract—the South West London and St George’s Mental Health NHS Trust. While I was president of the Royal College of Psychiatrists, I talked to the chair of the mental health trust about ways in which he could help us to develop our volunteer programme. We thought that Ghana would be a good country with which to establish a relationship, partly because of its political stability but also because we were aware that the trust employed a number of Ghanaian staff, and the catchment population included many West Africans. The scheme at our trust was helped off the ground by a charity called Challenges Worldwide, which helped to set things up in Ghana. The scheme involved the trainee volunteer forgoing one month’s salary to cover the overheads involved in setting up the placement. The royal college fundraises to provide bursaries to support trainees’ travel costs. I shall quote two recent trainees who have each spent three months in Ghana. One said:

“This was for me the best professional training experience of my life … The support I received was excellent”.

The second said:

“My placement in Ghana was the most fascinating and perspective-changing experience in my career”.

Let us reflect on the fact that the NHS has for many years received the benefit of large numbers of health professionals from low and middle-income countries. Does the Minister agree that the value to the NHS of supporting training placements overseas far outweighs any short-term local costs? Also, can he confirm that all medical postgraduate curricula include core competences in global health issues, and will he comment on what more the professional regulatory bodies can do to ensure that enough appropriately supervised and integrated global health training placements are provided so that trainees have a realistic chance of acquiring some of those core competences?

Autism

Baroness Hollins Excerpts

Tuesday 7th December 2010 Lords Chamber

[Earl Howe]

My Lords, we cannot mandate to NICE what quality standards are produced. However, the case for developing a quality standard for autism will be considered as part of work to commission a comprehensive library of such standards from NICE in line with our plans in the White Paper. NICE is already developing clinical guidelines on diagnostic pathways for autism, including one for children and young people with autism. That is scheduled to be published in September next year. On training, I cannot really add much to what I have already said to the noble Lord, Lord Low, but it is very high on the agenda.

[Baroness Hollins]

My Lords, in respect of the training of medical students to be able to provide, in their future careers, adequate and reasonable adjustments for people with autism, what does the Minister think can be done to develop sufficiently existing equality and diversity training so that there will be adequate understanding and adequate adjustments will be made?

[Earl Howe]

The noble Baroness raises a very important point. We know from general practitioners that they feel an absence of knowledge and training in this area. We are talking to the royal colleges about this.