Health and Social Care Bill

Baroness Murphy Excerpts

Monday 7th November 2011 Lords Chamber

[Baroness Greengross]

My Lords, I will speak to Amendment 33 in my name. I am pleased to follow the noble Baroness, Lady Williams, and the noble Lord, Lord Turnberg, because a lot of my work is concerned with the sort of inequalities they have spoken about. The noble Lord, Lord Turnberg, mentioned Professor Sir Michael Marmot. I have been privileged to chair the advisory group for the longitudinal study on ageing that he established. I have done that since it started. It demonstrates so clearly the terrible, almost life-or-death sentences that health inequalities impose on different groups in terms of their life expectancy. This is really something that is quite impossible for us to continue.

My other role as the lead commissioner on age at the Equality and Human Rights Commission means that I hope very much that we can, if we amend this Bill, achieve more positive healthcare outcomes. The Bill, in order to achieve that, must be explicit that improvements have to be achieved across the whole population, not just some parts of it. We know that one group whose needs are currently very often underprioritised and underrecognised is older people, particularly within the NHS. Sadly, ageism persists in clinical practice—very often older people lag behind other groups in terms of better healthcare outcomes. I am very concerned that unless a clear obligation to demonstrate that improvement is being achieved across the whole population, the specific needs of older people will continue to lag behind those of other groups or sometimes to be ignored and similar existing health inequalities may even be maintained and strengthened.

My amendment would define the Secretary of State’s duties to reduce health inequalities against three different criteria: the definitions of equality contained in the Equality Act 2010; different parts of England; and different socio-economic strata. In any subsequent reporting of progress towards reducing health inequalities, the Secretary of State would have to demonstrate consistency in the progress made against the three criteria.

My amendment would clarify the Secretary of State’s duties in relation to reducing health inequalities. I am afraid that without this in the Bill health service improvement may not reach everyone. There may be a failure to improve services for specific groups such as those mentioned within the list of protected characteristics. Clause 3 currently requires the Secretary of State to have regard to the need to reduce inequalities between the people of England with,

“respect to the benefits that they can obtain from the health service”.

The amendment to this clause would ensure that access to health services and improving health outcomes were an intrinsic part of the Secretary of State’s duties. Without guaranteeing improvement in access to services, there is a risk that there could be high levels of variation in the kinds of services the NHS provides across the country.

I have listed the equality characteristics detailed in the Equality Act 2010 which is not necessarily Members of your Lordships’ House. Too often it has been the case that health inequalities exist in part because people belong to one of the groups listed here and there is actual discrimination against a patient. In relation to specific treatments, patients are treated differently not purely on the basis of clinical decisions but on the basis of one of the protected characteristics, particularly age. For example, despite improvements in cancer outcomes, a 2007 study of breast cancer patients in Manchester found that older women are less likely than younger women to receive “standard” management for breast cancer and less likely even after accounting for differences in general health and co-morbidity to have surgery for operable breast cancer.

My amendment will ensure that the Secretary of State’s duties are clear and specific and that people across England can be sure their access to healthcare and the quality of the healthcare they need will be assured regardless of who is providing the service. The areas where the Secretary of State can demonstrate improvement in reducing inequalities should be balanced and fair in their focus. The risk otherwise is that commissioners will be incentivised to invest their efforts in improving health outcomes for those groups where they believe they can make the easiest and quickest gains and some groups, including older people, risk being shunted to the sidelines. This must not happen.

[Baroness Murphy]

My Lords, I have a great deal of sympathy with those who want to beef up this duty on the Secretary of State. I want to ask the Minister to explain why the public health function was left out—it is very specific about NHS responsibilities. I suspect the answer is that public health is in relation to other departments of state. He is shaking his head so perhaps that is not the answer. Working in the NHS one cannot but be aware of these profound inequalities. Within the first week of going as chairman to the east London health authority, three facts hit me in the face. First, in Hackney, people had only a 25 per cent chance of referral for a hip replacement as per the norm for England. Secondly, in Newham, mortality rates for bowel cancer after treatment were 30 per cent worse than elsewhere. It clearly emerged that there was a failure of referral to access, for, particularly, certain of the ethnic communities. Thirdly, on a visit to the community podiatry service, every patient was white in an area where the population was 25 per cent black and minority ethnic. Simply, no one had ever asked them the relevant question. Addressing inequality seems to be profoundly difficult on the ground: you must have the information and the wit to discover whether there is a problem of access, referral or discrimination and treatment, or whether there are underlying features of the illness that make inequalities difficult to address.

Health and Social Care Bill

Baroness Murphy Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Baroness Williams of Crosby]

My Lords, perhaps I may ask a couple of questions in this short debate and thank the noble Baroness, Lady Finlay, for her comprehensive presentation. This is a difficult area of the Bill. First, what happens with someone whose main residence is in one place but who is actually very dependent on out-of-hours care because of the nature of their job. There must be literally hundreds of thousands of commuters for whom the natural place they would like to go, due to the recollection of personal data and all the rest of it, would be the clinical commissioning group in their home area, but because they spend a great deal of time at work a long way away they will in fact depend on out-of-time services. I am troubled by the low quality of some of those services in comparison to what we might call mainstream NHS care.

The second question is perhaps easily answered. Can the Minister say something about the relationship of both new structures to NHS Direct? I am not clear as to whose responsibility NHS Direct will be. Will it continue as a kind of separate freewheeling service or be linked to a clinical commissioning group; and, if so, at which end of the spectrum would it be linked?

[Baroness Murphy]

My Lords, I am particularly concerned about the area-based issue because, like many people, I have been banging on for years about the importance of coterminosity between health and social services. However, my experience over the years has been that that has not made much difference to the co-ordination of care between health and social care.

I want to raise a point about the new arrangements. I understand that we are trying to move away from the old RAWP funding formulation, which has always been deeply unsatisfactory and open to political manipulation, to the funding of real groups of patient populations on a risk-assessment base. To achieve that, there is no doubt in my mind that you must have real people on real lists, whether or not that clinical commissioning group has a responsibility to provide for a population within the group. You must be able to work towards a funding solution for those clinical commissioning groups that reflects real need and moves away from the old area-based populations.

I think that that may be the response I would give the noble Baroness, Lady Finlay. I did not really understand the brief amendments in this group that were not specifically related to this question so I address my issues to that.

[The Lord Bishop of Chester]

My Lords, I completely support the amendment in the name of the noble Baroness, Lady Finlay, but wonder whether what she wants could be achieved—it might be a small step in the right direction in relation to legislation generally—by simply removing from the Bill the words “provided to individuals”. The term “individuals” has a jarring effect. “Provided to people” might sound a bit better, but “individuals” has a slightly impersonal feel, especially as we are concerned as a Committee and as a House about the “national” character of the National Health Service. References to individuals jar in that regard as well. Simply requiring improvement in the provision of services might achieve what the noble Baroness seeks in her amendment.

--- Later in debate ---

[Lord Layard]

My Lords, some years ago I had a meeting with a newly appointed Secretary of State for Health, although he was not that newly appointed—he had been there for three weeks. At the end of our conversation about mental health, he said, “You know, I’ve just realised something. I’ve been in this job for three weeks, I’ve had about 50 meetings and this is the first time I’ve heard the words ‘mental health’”. That says it all. That is how our health service is run and, unfortunately, how the priorities are set. I should just like to review four key facts to show why this is not at all satisfactory.

First, according to the official survey, one in six adults suffers from mental illness, mainly clinical depression or crippling anxiety disorders. These are serious conditions, as has been said. For example, a very good WHO study compared the debilitating effect of depression with that of angina, arthritis, asthma and diabetes. Depression is at least 50 per cent more debilitating than those conditions. That is why half of all the disabled people of working age in our country are disabled by mental illness. It is not a small segment but a massive chunk. It is the largest illness among people of working age.

However, coming to my second point, only a quarter of those who are mentally ill are in treatment, compared with more than 80 per cent of those with the kind of physical illnesses that I mentioned. Last year the chairman of the Royal College of General Practitioners wrote to his members with the question: if you have a patient who needs psychological treatment, can you get it normally, sometimes or rarely? Only 15 per cent said “normally”. That is the situation that we are in, which is shocking. The treatments that are available are good. They are recommended by NICE but simply not delivered on a proper scale, even though they are meant to be delivered according to the NICE guidelines.

Thirdly, what is even more extraordinary is that these are cheap treatments. It is quite easy to show from the experience of the Improving Access to Psychological Therapy programme, for example, that they completely pay for themselves through savings on out-of-work benefits, lost taxes, unnecessary visits to the GP and unnecessary references to secondary care. However, if we ask what commissioners’ priorities are, these treatments are of lower priority than many of those for physical conditions that are often much less disabling.

Finally, what is so extraordinary about this, as other speakers have said, is that the problems of people with mental health difficulties also rebound on their physical condition. We also know that many physical conditions rebound on mental conditions. Many physically ill people—those suffering from angina, lung disease or a stroke, for example—suffer from depression. Several proper clinical trials show that, with proper psychological treatment of these mental conditions, the physical condition will improve to the extent that all the money is, again, repaid in savings in physical care. Therefore, we should give much more priority to these conditions.

We also see cases where people are referred with physical conditions that have no physical explanation. Something like half of all referrals to the secondary sector fall into that category of medically unexplained symptoms. Again, many of those will respond to psychological treatments.

Despite all this, we all know where mental health stands in the priorities of commissioners. It counts if there is a serious risk of homicide or suicide. Then they really get to it. However, if not, it is, unfortunately, the easiest area to cut, which is happening on quite a scale at the moment. Two years ago the regulator, Monitor, recorded the fact that mental health services are cut by more than physical health services whenever there is a shortage of money. Monitor recorded this in its advice to trusts on how to budget in the future; it was part of its guidance. It is invariably the case that mental health is cut more than physical health when there is a shortage of money. It is just extraordinary. That guidance was eventually recanted but it is the reflex throughout the commissioning world. I am making the point that this is not only important but a very big thing. That is why it is important that we include the phrase “physical and mental illness”, and do so from the beginning of the Bill. If we do not, people will tend to forget mental health, as the department did for three weeks when it was briefing the then Secretary of State. I urge the noble Earl to take this amendment very seriously.

[Baroness Murphy]

My Lords, I rise briefly to support the eloquent speech by my noble friend Lady Hollins and other noble Lords who have spoken in this debate, if only to give the House a hat trick from the psychiatrists who are here today.

In 1845 the Lunacy Act first separated physical and mental health with the building of the asylums. Before that, in the Poor Law Commission’s provision of service to the general population, around 30 per cent of the medical time of general practitioners and specialists who were engaged by the Poor Law Commission was spent on people with mental health problems and what we would call learning disabilities. That division, however good it was in developing the services in other ways, has led to a separating out which continued after 1948, to the detriment of the development of services.

This Government and their predecessor have done an enormous amount to right that imbalance. As I have pursued my career in psychiatry, I have seen a dramatic difference in the investment that has been made in mental health services. However, there is still a lack of parity and when people talk about illness they still mean physical illness. I do not know whether the wording “physical and mental” is quite right in this amendment. However, it seems to me that the time is right to have an explicit provision on the face of the Bill regarding the equal importance of mental health and physical health in building a healthy nation. Unless we address physical and mental health together, we will not improve public health. It would be a good time to get such a provision in this Bill as it moves forward with a new style of NHS. I hope the Minister agrees that this is too important a matter to let it go.

Health and Social Care Bill

Baroness Murphy Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Baroness Murphy]

My Lords, this is a topic very close to my heart. The delivery of social care is almost wholly towards people with health problems; if you do not have a health problem, a disorder or disease, you will not be in receipt of social care. But we have always had this curious distinction between who delivers what. We have had these great silos whereby enormous amounts of spending in the health service would be better spent transferred to social care services. We have known that for years and years, but it has not really happened as fast as it should have done.

The commissioning and delivery of services has been almost wholly down these isolated silos. We have tried to chisel away at this over the years with joint trusts for delivery of services to children and other joint trusts for delivery of services to mental health, and so on. But for the mainstream older person coming through healthcare services, we have not had that integration very effectively, and we have therefore wasted money buying health services when we should have been buying social care services. So it is crucial that people get better cost-effective packages of care, which include the whole pathway.

It is also true that we have a system at the moment whereby in the past 20 years we have moved hundreds of thousands of seriously disabled older people out of NHS care into independent sector nursing homes and, in the beginning, local authority care homes and contracted private homes, leaving behind the teams of people—healthcare professionals, medics and nurses who used to care for them in hospitals—completely isolated back in the hospital. They are not delivering those community services that the independent sector nursing homes and local authority care homes so desperately need to provide—comprehensive health and social care service in residential care. It has always seemed extraordinary that we have allowed these silos to grow up, whereby the person sitting in the hospital, the consultant geriatrician or the psychogeriatrician, does not think that it is their business to provide a service for the wider community of patients in their patch. It seems extraordinary to me that we could have got ourselves into this position.

We need something to move back again to a situation in which people think epidemiologically about a community, about how the best services could be provided from vertically integrated care between hospital and community services—and of course that community care must start with what comes from primary care—but also fundamentally from what is commissioned from social care as part of the package. Perhaps we can get it in somewhere in this Bill that we need to do this. We all know about Kaiser Permanente and the examples of how it works in the States. It works very effectively when you can commission from a range of services across health and social care directly. That makes a great deal more sense than trying to narrow the trenches; a trench always pops up somewhere else when you chisel away at a trench between local authorities and NHS authorities. You do not need to do that if you are very clear about commissioning a package of services across the divide and across NHS primary care and social care. This is extraordinarily important as the population continues to age and, without it, we will not be able to generate that wonderful £20 billion of savings that we are always going on about. We will get better value for money if we contract across an integrated care pathway across health and social care.

I do not know whether this is the right point to get this proposal in. Like the noble Lord, Lord Warner, I am sure that it should go somewhere and that we should have a real commitment in the Bill. If it is the right point, we can get people to translate this into the sort of unbundled tariff that we need to get the financial packages right and move away from the counterproductive system of payment by results. Unfortunately, that again tends to fossilise an old-fashioned way of doing things, which is too expensive. I give my full support to this amendment.

[Baroness Pitkeathley]

My Lords, my name is added to some of these amendments and I will add little to the eloquent speeches of my noble friend and of the noble Baroness and the noble Lord from the Cross Benches. I want to endorse only the important points of principle that they have set out. As someone who has spent a large part of a long working life at the margins or the crossover points between health and social care, I am only too well aware of what goes wrong if you do not have proper integration. It is very important, as the noble Lord, Lord Patel, reminded us, to come at this from the experience of the patient, the user and the carer. Their needs rarely come neatly packaged as health and social care; there is always crossover between them. That is especially true in the case of long-term illness but it is also a concern to those who have had an acute episode, especially in these days when people are discharged early from hospital but still need medical, nursing and social care at home.

Almost 40 years ago, I wrote a book called When I Went Home, a study of patients discharged from a local community hospital. One patient I interviewed said to me, “What I don’t understand is why they don’t talk to each other. Why did they discharge me without arranging it with my family—without even telling my family I was coming home—and why weren’t the services I needed at home all geared up for when I got there?”. I have lost count of the number of times that I have heard this story repeated over the years. Patients, users and carers do not understand different funding mechanisms, professional boundaries or sensitivities about exchanging information—and why should they? We have been saying for at least 40 years that we must improve integration. Let us for goodness’ sake use this reform as a means of achieving more commitment to integration, to which everyone pays such a lot of lip service but which in reality is still sadly lacking.

I must emphasise that we are at a point where not only do we risk not making integration better but where it could become worse if we do not really emphasise the importance of integration in this legislation. I am thinking of things such as the pressure on local authority budgets and on the voluntary sector, which is so often such an important part of an integrated care package. I am thinking of the mismatch in timing between the reforms in social care and those in the health service. I always think, too, that we should remember that it is people, not structures, who promote integration. Those currently employed in health and social care are working in a confused situation. They are often uncertain about their futures and their working relationships. They are therefore really not in a good place for cutting across professional boundaries and perhaps giving up some of their power to develop the flexible ways of working which are so necessary for integrated services. We owe it to them, as well as to the patients, users and carers, to be as explicit as possible about the importance of integration. I hope we will do that in this Bill.

Health and Social Care Bill

Baroness Murphy Excerpts

Tuesday 25th October 2011 Lords Chamber

[Lord Hennessy of Nympsfield]

My Lords, having suggested during the Second Reading debate that your Lordships might consider the value of a preamble to the Bill which captures the ethos and purpose of the National Health Service, I was grateful to the noble Earl, Lord Howe, in his letter of 20 October to noble Lords, for describing it as “an interesting idea”. The Minister went on to say that,

“preambles have fallen out of use in modern-day legislation, partly because there is a risk that they could lead to unintended consequences, and also because it is considered bad legislative practice to include words in a Bill that have no clear legislative purpose or effect”.

I note and accept that preambles have fallen into disuse, but I continue to see the value of capturing the NHS ethos and purposes firmly right at the top of the legislation, which is why I welcome the proposed amendment in the name of the noble Baroness, Lady Thornton, as a surrogate for a preamble.

I am especially pleased by the NHS constitution occupying a prime position in the amendment’s attempt to capture the principles of the health service in England. The first two principles expressed in the NHS constitution must continue to suffuse the whole enterprise and its legislative underpinnings. The first principle declares:

“The NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief. It has a duty to each and every individual that it serves and must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population”.

Principle 2 explains quite briefly that:

“Access to NHS services is based on clinical need, not an individual’s ability to pay. NHS services are free of charge, except in limited circumstances sanctioned by Parliament”.

Faith in those principles runs deep in our country, powerfully and, very largely I think, consensually. They deserve to be emblazoned at the top of this Bill through a clear reference to the NHS constitution. In fact, apart from the words “not the market”, the amendment before us could, I suggest, represent a common bonding for our deliberations, however fiercely contested will be many of the clauses to come, just as the sustenance of a comprehensive National Health Service free at the point of delivery is one of, or perhaps the most, tenacious common bondings of our people and our country.

[Baroness Murphy]

My Lords, one cannot help but be moved by the commitment of the noble Lord, Lord Hennessy. In view of the public discussion that has gone on outside this Chamber, we all welcome a recommitment to the principles of the NHS constitution. But I have a number of really serious concerns about the amendment as it stands. For a start, remembering back to the 2009 Act, the whole point about the NHS constitution is that it was not just a set of airy-fairy principles, it concerned how those principles were to be put into effect. To extract these crucial principles, which along with the noble Lord, Lord Hennessy, I wholly support, and put them separately at the beginning of the Bill is to confuse the issue and, I think, to leave us open to further legal challenges over what the NHS is about. The NHS constitution stands; that it must stand is reiterated in the Bill, and therefore we should not seek to water it down in any way.

The second part of the amendment again does not quite reflect what we have tried to do, as we discussed the development of this Bill, to ensure that the NHS is about improving quality. It is not about accepting quality, equity, integration and accountability as is; it is about continuous change leading to improvement. Again, I think that that is not reflected in subsection (2), which is very confused, and I really do not understand the phrase at the end, “not the market”. What does that mean, and how does it relate to the,

“person or body performing functions”?

The third subsection, about the primacy of patient care, is crucial. We want to see the primacy of patient care throughout the Bill. Again, however, as it stands, the amendment would rule out structural and financial reorganisations, for example to improve the formula for allocation of resources to local clinical commissioning groups. It would rule out the decisions that we want local groups of commissioners to make regarding reconfiguration. It would stultify the development of an improved health service. I really think that that is confusing.

As for the Nolan principles, I think that all of us would say that they are crucial. But they are in the Bill as it is, as they were in every NHS Act recently. Standards in public life are something that everybody who is in public service must be committed to, and they are in employees’ terms and conditions of service. These are desirable things, and I am very sympathetic to the desire to make a comprehensive statement of the commitment of all sides of this House to a universal and comprehensive NHS. However, this amendment is not it.

[Baroness Jolly]

My Lords, I do not intend to take an awful lot of your time with my comments. I agree with many comments made by my noble friend Lady Williams, and I share the anxieties expressed by the noble Baroness, Lady Murphy. To a certain extent I am bemused, because we have a perfectly good NHS constitution. It has been said that it is only three years old and indeed it is. It was a result of the work of the Labour Peer the noble Lord, Lord Darzi, and involved a huge cross-party effort. This is to be commended. This amendment does not match it in breadth or scope.

We are now in Committee and it is not sensible of us to prolong the debate. We have many, many days yet to go and we really need to move on and get on with the Bill. However, I want to finish by thanking the noble Baroness, Lady Thornton, for her compliments about our conference motions and the way in which our policy is made following votes by our members at conference. The second subsection of this amendment came from a motion to our conference last spring. We wanted the NHS to work for patients and not providers and as a result of this and the Future Forum deliberations, this was acknowledged. Furthermore the Monitor duties were changed to reflect this so that they now are about the promotion and protection of patient care. I really feel that we need to move on and get on with the Bill.

Health: Non-communicable Diseases

Baroness Murphy Excerpts

Thursday 6th October 2011 Lords Chamber

[Baroness Murphy]

My Lords, I add my voice of thanks to the noble Lord, Lord Crisp, for securing this debate and for the opportunity that it gives us to talk about the scourge of these five chronic diseases. This is also an opportunity for me to express my personal admiration for his commitment in recent years to the cause of improving global healthcare through the improvement of the education of healthcare workers in developing countries. I wish all strength to his arm in that area.

Before I go on to talk about mental health—which will be no surprise to anybody because everyone knows that that is what I do—on behalf of the well rounded of this world I want to pick up on something that the noble Lord, Lord McColl, said. He is absolutely right that the obese should eat less and that we should all eat less—that is a message that comes over strongly—but I should like to point out that an obese individual losing weight permanently by eating less is as likely as a heroin addict coming off heroin. It is almost impossible. We must go back to the comments of the noble Lord, Lord May: we need population solutions; we need to support people to eat less; and we will need to tackle the food industry to do so. I am sure that the noble Lord, Lord McColl, will forgive me but it is an issue which is so easy to say but so difficult for many people to follow.

As we have heard, the World Economic Forum, which through the Harvard School of Public Health did the research on the anticipated costs of these five chronic diseases, found that mental health will account for one-third of the overall $47 trillion. I am not sure that I can take on board what a trillion is, but a huge amount of money—about one-third of the anticipated costs that NCDs pose—will be lost due to the dependence of people with mental health problems. As a result, countries and economies are losing people in their most productive years. About 70 per cent of lost economic output is due to mental illness and heart disease alone. That means that it is the largest burden of disease globally, measured by disability-adjusted life years; there is a greater economic toll globally from mental disorders than from any of the other major disorders. I suppose that that is not surprising, as the human brain is the seat of all higher intellectual, emotional and cognitive functions, which are essential for individuals to fulfil their fullest potential. Many of these disorders begin in childhood and adolescence—a critical period of life when an individual is being educated, establishing effective social relationships and laying the ground for a successful career.

Even in the least developed regions, where infectious diseases are prominent and still important sources of disorder and disability, mental and neuro-psychiatric disorders remain and are a growing source of disability. Suicide claims the lives of 800,000 people annually. That is clearly a gross underestimate; the way in which we collect suicide statistics is very poor. Over 90 per cent of the 24 million people suffering from schizophrenia reside in low and middle-income countries, and less than half those 24 million receive any treatment, even in developed countries. Some of the treatments available in near neighbours such as eastern European countries are pretty frightening. There are still some profound human rights abuses in some of our neighbouring and many developing countries, akin to the sorts of treatments that were available here in the medieval period. They are still happening in many countries. Countless millions of mentally ill people go untreated, suffer misery and poverty and, quite often, grave human rights abuses.

The World Economic Forum research was published just a fortnight before the UN meeting on non-communicable diseases, which was billed as a once-in-a-generation opportunity to tackle the predicted wave of the diseases. I cannot but express my disappointment that mental health was scarcely given a mention. It was not on the agenda and the final communiqué had three and a half passing mentions of it. Our Government were urged to promote mental health at this meeting but did not do so. How are we to get the countries of the world to take it seriously if our Government do not?

We can guess why these disorders were ignored. The problems of stigma, the rejection of mental health patients and the denial of how economically important they are, are all too frequent. But of course there are unique challenges associated with mental disorders because of the cultural influences in the manifestation of illness, the stigma which attaches to family and healthcare workers as well as patients, and pervasive misunderstandings about causes and appropriate treatments. Most diseases have straightforward diagnostic systems that are relatively impervious to the influence of culture and context, but mental disorders are hampered by shifting and imprecise diagnostic systems, a weak evidence base for their causality and a lack of awareness and resources for appropriate assessment. The treatment facilities for mental disorders are generally segregated from those for other health problems. That is a problem that goes back to the way in which European colonialists often viewed these disorders in the past two centuries and has resulted in very fragmented funding streams, haphazard training and care pathways. In many countries, the system of care is based around a single large, rare specialist facility, often in an old mental hospital—maybe one per country in an urban centre—which provides for a tiny fragment of the country’s mentally ill and separates people from the care of the community where patients and families live. There is a need for decentralisation of services to scale up access to treatment and care. We now have evidence-based knowledge of very effective treatments and delivery systems that can be adapted to meet the needs of different cultures.

This morning I was talking to Professor Martin Prince, who is Professor of Epidemiological Psychiatry at the Centre for Global Mental Health at the Institute of Psychiatry. I asked whether he could give me some up-to-date good examples of where some new cost-effective delivery systems were in place. He particularly wanted me to mention two excellent services. One is in Goa and is being delivered by community mental health workers, picking up antenatal depression across large numbers of people in the community. I understand that the cost of treatment there is less than the cost of a loaf of bread a day, so it is extremely cost-effective. There is another one around Rawalpindi in Pakistan, where a system of community mental health workers provides basic community mental healthcare across a very wide area on an algorithm that reaches a primary care physician for those where the provision of community mental health workers is uncertain. Again, that is extremely cost-effective, and it is very well researched to show how effective it is in bringing sustained benefit over a number of years. There are many examples such as those.

To echo the point made by the noble Baroness, Lady Hayman, we have a lot to learn from some of the systems that have been put in place. There are some very cost-effective, economical and simple ways in which to pick people up and treat them early, using people trained with specific tools over short periods of time. Nevertheless, these are isolated good examples that I can quote—there is an enormous gap—and the time for global action has come.

Sadly, while we know that mental health is integral to achieving social, economical and health goals of development, it continues to get short shrift. It needs to be included explicitly and independently as a key component of discussions and recommendations. The World Federation for Mental Health has set up a convention of working groups to aid the United Nations in developing guidelines, goals, tasks and outcome measures—all those United Nations phrases which I suspect sometimes do not lead to much action. However, we have to start somewhere. There is much good work going on and it deserves government support.

Finally, can the Minister explain why the Government, whom I will praise for having done so much to foster mental health as a priority at home, have not given a vigorous lead at the United Nations? I understand that this particular meeting wanted to get some action on smoking, diet and exercise—particularly smoking—and that there was some hard stuff to be done. I understand the importance of that, but it does rather play into the hands of the ignorant, stigmatising mental health yet again by denying its crucial importance to suffering and national economies. What plans do the Government have for putting right that neglect of mental health on an international stage? It is really one of those disorders that we cannot stand by and ignore.

NHS: Standards of Care and Commissioning

Baroness Murphy Excerpts

Thursday 31st March 2011 Lords Chamber

[Baroness Murphy]

My Lords, I shall hark back to much of what the noble Lord, Lord Turnberg, said in his admirable introduction to this topic. The stories in the ombudsman’s report are so shockingly familiar to us, yet we still find it very difficult to take in that they reflect the norm. The National Confidential Inquiry into Patient Outcome and Death in surgery for elderly patients found that only 38 per cent got good care. It is not just that care is neglectful to the point of cruelty, but that families that try to intervene are actively discouraged and largely ignored and the denial by managers is a cultural norm. I found that I could not save my own mother-in-law from truly appalling care in a suburban London hospital, and my own mother’s recent care in a Midlands teaching hospital was pretty variable, too, depending on the team that was on duty.

I have heard people minimise the significance. Apparently the NHS has improved over the past few years and patients say that they are very satisfied with the care that they get. It may well have improved, but the very aged do not respond to these patient surveys, and in any case it is their distressed kith and kin we should be surveying to get an accurate picture. My mother would not let me complain because they fixed her hip, did they not? The Patients Association has been flagging up the truth for years and the majority of senior managers know that Mid Staffordshire Hospital was not an outlier on the graph by any means.

The usual response to a scandal is to launch an inquiry, and I have sat on many myself. Typically they make vast numbers of recommendations that are then translated into points for action with a monitoring schedule for ticking off the boxes. Schedules will be cascaded and all will get a bit better. There are marginal improvements locally, but nothing really changes. What is the answer? More inspection? I do not think so. The CQC knows that the self-monitored standards of dignity that hospitals claim to have reached are often a fiction. Inspection never picks up more than a snapshot. Unannounced visits are helpful, but they are too infrequent and superficial to be realistically helpful. Regulators simply cannot substitute for caring staff. More training that treating old people appallingly is wrong? I do not think so. We all know it is wrong, but we learn by example from our seniors. If that counts as training, then perhaps training is needed. More geriatricians and psychogeriatricians like me? We need champions in medicine and nursing—but no, this is every clinician's business, not a specialty.

I agree with many colleagues who have spoken before that getting the teamwork and ward processes right might help a bit. It is noteworthy that these episodes of poor care do not occur on specialist wards where unified teams work together under good leadership. We have tended to undermine teams on general wards in the misguided and counterproductive chase for efficient turnover. I harp back to Professor John Yates’s earlier studies, which show that it is vulnerable patient groups, local ward staff left to their own devices and staff not included in team support who fail.

My recipe comes back in part to unannounced regular inspections by HealthWatch and the regulator and to surveys of family carers. However, hospitals reflect the wider attitudes of society. We should look properly at the price of care, and we should stop commissioning specialties such as cardiac, cancer and renal at a higher tariff on the care price compared with medicine for the elderly and general surgery. The funding imbalance is profound and reflects the poor value which society puts on the everyday care of the most vulnerable. Therefore, the commissioning sensitivities that GP consortia will have will be crucial. We know from studies in the States that commissioning cannot be the whole answer; it is the providers who are important. However, we should not necessarily ignore commissioning. It is vital, but ultimately it is the care design in hospitals and structures that really count.

Health: Mental Health Strategy

Baroness Murphy Excerpts

Monday 14th February 2011 Lords Chamber

Asked By

[Baroness Murphy]

To ask Her Majesty’s Government what plans they have to implement their new mental health strategy.

[Baroness Murphy]

My Lords, 10 days ago, the first ever cross-government mental health strategy was launched, laying out plans for the future of mental health care in England. I congratulate the Government on recognising the crucial fact that mental health affects every area of a person’s life and impacts upon their ability to play an active role in society and I welcome the Cabinet-level commitment expressed so far. The strategy also makes plain that mental health has a parity of esteem with physical health—a lovely phrase—finally giving the issue the equal footing it deserves.

Sticking with the good things for the moment, I am delighted with the commitment to repeal the outdated law which forces MPs to stand down if they have been sectioned under the Mental Health Act for more than six months. This is an important anti-stigma signal by the Government.

However, I turn now to my—what shall I call them?—not exactly anxieties or worries but a sense of unease about the messages. I had niggles about the New Horizons strategy from the previous Government, so I am not blaming the coalition; rather I am blaming all of us in government, professional organisations and the voluntary sector for letting the ball slip through our fingers. I declare a personal interest¸ having spent most of my career working in specialist psychiatric services with people with serious, life-changing mental health disorders such as dementia, schizophrenia and other major psychoses and serious disabling developmental disorders of personality.

For me, the overarching theme of the strategy represents a misguided, somewhat soft-headed, utopianism focused on well-being and mental good health, as though there were a direct connection between a happy society and reduction in serious mental illness. But there is not. Events and circumstances, often unavoidable, play a significant part in the origins of serious disorders—but only a part, and often a very small part.

Let me make it clear that the broader public health issue of mental well-being and the aim to intervene to prevent the experience of distress are legitimate national strategic objectives. The toll of emotional human misery and minor psychiatric morbidity costs England an estimated £105 billion every year. This burden spreads beyond health services to education, employers, the social security benefits system, housing, the criminal justice system, families and communities. National well-being should influence our approach to economics and it is entirely legitimate to try to intervene to promote good mental well-being. However, I have doubts as to whether this should be the target of a mental health document which will largely be read by health and social care providers.

Many in the Chamber today have campaigned for the wider availability of psychological therapies, but again I have doubts about what Marjorie Wallace at SANE has recently referred to as the “therapy for the nation” strategy, which comes across as a panacea for the whole spectrum of mental health conditions and is being launched against a background of active planning for cost improvements of about £20 billion in the NHS, with local authorities shamelessly slashing and burning community services.

The experience of many local voluntary organisations which work with people with serious mental disorders is that people are being turned away from help, especially from in-patient care, when they feel desperate or they and their families have reached crisis point. Mental health services are still not getting it right for people with serious mental ill health and I want a strategy that does. Only today I received a deeply moving letter from the mother of a young man with a chronic enduring psychotic illness whose life circumstances were extraordinarily tragic and who was receiving inadequate support from the community services.

I am particularly critical of the public health outcomes framework in the strategy document, which seems to me to be mostly aspirational wishful thinking. It includes everything from reducing reoffending and self harm, all the way through to access to green spaces and “improving social connectedness”—a Facebook account for all? It is all lovely stuff but nothing to do with mental ill-health realities.

We know from studies in the US and our own research that social interventions that make a difference—for example, to the mental well-being of children and young people—have to be comprehensive, very focused, usually costly and require major changes in the way services are organised. Successful pilot schemes have been exceptionally difficult to replicate on a larger scale and to translate from experience in the United States. It is a waste of time, as we have known from so many social interventions, to intervene with individuals and families on a small scale, yet there is a real danger that that is what we will do.

Let us take maternal depression as an example. I am not denying that there is some evidence for the efficacy of preventive interventions, such as home visiting, parenting programmes, peer support, the refocused Sure Start children’s centres, parent support advisers working with school staff, and other family support workers, such as health visitors and early years outreach workers. Your Lordships may have noticed that I have already mentioned an army of helpers and workers of one sort or another. Then there is the family-nurse partnership programme, which works with the most disadvantaged young families with complex, interlinked problems and is aimed at interrupting the transgenerational cycle of poor health. The evidence is poor that this will work unless it is properly replicated on a very wide and expensive scale. The Government have pledged to increase the health visitor workforce by a further 4,200 posts, refocusing health visitors on maternal and infant mental health. However, the overall evidence for the efficacy of health visitors has been slight in the past. The NICE report currently on its website is based on an earlier Health Development Agency review of the evidence, which did not give much comfort in this area. Research has been small scale; much of it is interesting and encouraging, but its findings have so far been modest. Yet we are about to embark on vast investment.

To support these and other programmes, the Department for Education has introduced a new early intervention grant, which will bring together funding for a number of intervention and preventive services. These will replace the current targeted grant. I have no quarrel at all with the idea of a general grant that local authorities can use for the priorities in their area, but altogether the early intervention grant will be 11 per cent lower than the aggregated funding for this year, with a further major drop for next year. What of the £400 million extra for psychological therapies, which can and should, in my view, be targeted on those with the greatest need? It is in the baseline funding of the NHS, but do we really expect that it will be spent in the suggested fashion in the context of the £20 billion reduction? Some of it will be retained by a few areas, but I have grave doubts that it will find its way through to where it is really needed.

I suggest that a mental health strategy should focus primarily on those with the most severe disorders, whose lives are so often wrecked by the misery of mental illness. It has to be fit to be translated into measurable outcomes for the commissioning board and turned easily into commissioning intentions by GP consortia. We know that GPs lack confidence in commissioning mental health services. A survey last year by the charity Rethink found that, although three-quarters of GPs are happy to take on responsibility for commissioning diabetes and asthma services, fewer than a third feel the same for mental health services. They know that they do not like what they get at the moment for their patients with severe mental illness. Only half of GPs are confident about the quality of specialist care for depression and only a third are confident about the quality of care offered to people with psychosis. Many GPs doubt that patients with mental ill health will get the treatment that NICE recommends. In a way, that should encourage us, because GPs will want change for the better. I know that the Mental Health Network of the NHS Confederation is doing some very good work in collaboration with the pathfinder consortia.

The well-being of the nation is an important thing, but it is perhaps something other than a mental health strategy, so does the Minister not have doubts about whether we know enough to intervene cost-effectively or whether we have the public wealth to intervene on a wide enough scale to make a real difference? Will he accept that the well-being of a nation does not have a great deal to do with the sorts of services that will be delivered to people with serious and enduring mental health problems? I should like to see a strategy that really gets it right for the seriously ill.

Finally, I look forward very much to hearing other noble Lords on this topic. I firmly expect them all to disagree with me profoundly and I hope by the end of this debate to be converted back to my usual optimistic self.

[Lord De Mauley]

I have been informed that at least one noble Lord has withdrawn his name from the list of speakers for this debate, which means that all speeches, except for that of the Minister, will be limited to six minutes.

Health: Chronic Obstructive Pulmonary Disease

Baroness Murphy Excerpts

Wednesday 17th November 2010 Lords Chamber

[Earl Howe]

My Lords, my noble friend is absolutely right. We have been working with the breathe easy groups and the British Lung Foundation to ensure that the good work that they are doing, along with that of the newly appointed strategic health authority respiratory leads, will improve outcomes for those with COPD and asthma. I agree with him fully that this is a very good example of the big society in action.

[Baroness Murphy]

My Lords, patients with COPD are classically those who do not get access to palliative care services at the end of life. Will the Minister tell us what the Government will do to improve the access to palliative care of patients with COPD and other chronic conditions at the end of life?

[Earl Howe]

My Lords, the noble Baroness will know that an enormous amount of work is going on with palliative care services, and a great deal of money is being directed towards them. I share her concern that hospices tend to focus above all on patients with cancer, to the detriment of those with other conditions. This is an area that we are looking at very closely.

Mental Health

Baroness Murphy Excerpts

Wednesday 10th November 2010 Lords Chamber

Asked By

[Baroness Murphy]

To ask Her Majesty’s Government what plans they have to address mental health factors in their public health agenda.

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

My Lords, mental health is recognised as an integral part of public health. The public health White Paper will set out a new approach to public health, giving mental health the same prominence as physical health conditions such as cancer and heart disease. The Government recognise that there is no public health without public mental health.

[Baroness Murphy]

I thank the Minister for that encouraging reply. Of course, he will recognise that there is a long way to go. Some 50 per cent of all smoking related deaths in this country are attributed to people with mental disorders, and in fact those with mental illnesses account for almost half of all the tobacco consumed. People with schizophrenia and other mental illness have by far the worst outcomes in terms of mortality, losing on average 20 years of their lives. Will there be specific targets in the forthcoming White Paper around the physical health outcomes in terms of mortality and morbidity of those with serious mental disorders?

[Earl Howe]

My Lords, yes. We know that people with severe mental illness die on average 20 years sooner than others and that the majority of these deaths are smoking related. Improving public health is at the core of the Government’s health policy, as I expect the noble Baroness is aware. We will make clear our priorities in this area when the public health White Paper is published.

Queen's Speech

Baroness Murphy Excerpts

Thursday 3rd June 2010 Lords Chamber

[Baroness Murphy]

My Lords, I, too, warmly welcome the noble Earl, Lord Howe, to his role on the Front Bench. I am sure that he will forgive me for saying that he has been practising diligently for this role for more than 10 years. We now have a Secretary of State and a Minister leading in the Lords in health who have a solid understanding of health policy. That is a great good fortune for those of us who work in this area. While I suspect that parts of the policy are still a work in progress—social care is probably the fuzziest at present, and I hope that noble Lords were listening to the noble Lord, Lord Sutherland of Houndwood, on this point—I welcome strongly the direction set down in the gracious Speech, and the indication that we shall now speed ahead to reverse the unhelpful dithering and procrastination of the past two years.

I declare an interest as a member of the board of Monitor, the NHS foundation trust regulator, and chairman of St George's Hospital Medical School, University of London—although not for long, as I am retiring this summer from both roles. The future agenda is exciting, both for improvements in healthcare and for the impact that such policies are likely to have on health sciences education. I welcome and will support the intentions of the forthcoming health Bill. The coalition agreement, based on pre-existing Lib Dem policy and the Conservative Party publication NHS Autonomy and Accountability, is entirely welcome.

First, I will highlight the news that research into the dementias has become a government priority. This is music to my ears, as it is my specialty, and makes economic as well as clinical sense. I look forward to seeing how it will be effected in reality, given the inevitable pressures there will be on research council funding.

I welcome strongly the intention to complete the shift to a health system where decisions are made locally by patients and professionals rather than centrally, to complete the separation of commissioning and provision, to get all hospitals to foundation trust status, to improve the information available on the quality of care so that better decisions can be made and to put the setting of incentives in the system on a more professional basis by establishing an independent economic regulator of health care. For a system of tax-funded healthcare to be sustainable in the long run, we need better incentives and more local decision-making and innovation. These changes will be very helpful for that.

There is now incontrovertible evidence that competition between hospitals and between service providers improves both innovation and health outcomes if the system is well regulated to ensure a financial level playing field and the quality of care is subject to rigorous monitoring and improvement. Too often in the past, the internal market was left to its own devices and subject to central interference. It worked to keep down costs but did not necessarily improve quality. The BMA and other professional bodies have been rightly critical of it. However, recent evidence from the Centre for Economic Performance at the LSE and other independent studies by US-based researchers of health outcomes in heart disease treatment in English hospitals have confirmed that a properly regulated market has a positive effect on outcomes, including saving lives—about 400 lives in heart disease treatment. This is especially true when clinicians are in real and powerful leadership roles.

I am sure that we will have many happy hours scrutinising the details as the Bills come before the House. We do not yet know what some of these details will look like. In particular, I do not really understand what the relationship will be between a national commissioning board and local GP commissioners. Finding the best way of organising how we spend £100 billion on healthcare continues to be the most significant unresolved question in the reforms. Commissioning decisions need to be made at a sufficient scale to support the right level of analysis and expertise but also close enough to the clinicians who actually make the spending decisions to influence their behaviour and to reflect local circumstances. How will we prevent groups of GPs from delegating their commissioning to junior administrative staff, as they consistently have done in the past? The benefit of small-group GP fundholding has proven extraordinarily difficult to replicate on a larger scale and I look forward to hearing how that can be done.

How will we get all hospitals to foundation trust status? Only half the acute hospitals and three-quarters of mental health services have so far managed to demonstrate that they are sufficiently financially robust and well governed to stand on their own feet and to operate independently. Strategic health authorities have truly struggled in preparing applicants, so we will need a better approach to help the remaining trusts to get up to the required levels of competence. FT status is not about achieving some label; it is about putting the management and finances of the trusts on a sound footing for the challenges ahead.

Will FTs be subject to Treasury spending controls? If so, this will significantly reduce their freedom from central interference and undermine the intention of the Bill to allow more local decision-making. A way of preventing that would be to adjust the FT regime sufficiently to allow the trusts to be taken off the Government’s balance sheet. We could have, as an alternative to Treasury controls, strong regulation and a clear failure regime to ensure sound finances.

I am challenging the Government to show the kind of bravery that will really move the health service forward. When the Blair Government took office, they had some very good ideas and it is not surprising that the new Government are trying to improve on those good ideas. However, the Blair Government did not implement them quickly enough—it took them five years to get started—and latterly the policy sank into the doldrums, besieged by old party slogans. Although this Government now have the opportunity to act, they must truly get on with it. They cannot improve care directly; only front-line clinical staff can do that, as the noble Lord, Lord Kakkar, said in his maiden speech. However, they can provide the structural context in which improvement of care is likely. I disagree that all structural change is unnecessary or unhelpful. Sometimes structural change is necessary to ensure that something completely different is delivered. In this case, I think that we should continue the structural changes that have been begun but do so more quickly. Therefore, I urge the Government to go as fast as they can; it is our health and our lives that are at stake.