Contraceptives and Hormone Replacement Therapy Drugs

Lord Alderdice Excerpts

Wednesday 18th March 2020 Lords Chamber

[Lord Bethell]

The noble Baroness, Lady Thornton, is entirely right that supply problems persist. The NHS looks after 11,000 drugs and at any one time around 100 or 150 have supply problems. It is a great frustration to those concerned and we are cognisant that HRT has been a persistent problem for more than a year. However, the outlook is positive. I reassure the House that Covid-19 has not had an impact on the supply of HRT. We do not envisage there being a connection or a problem. I share the noble Baroness’s concerns that online pharmacies might take advantage of the situation, but it is a marketplace: it provides choice and is regulated.

[Lord Alderdice (LD)]

My Lords, when women go to the chemists to get their prescription, they might well find two problems. The first is the one the noble Baroness mentioned—inadequacy of supply—but it is also increasingly likely that pharmacists themselves will fall ill, so not only the advice, but even the dispensing of available pharmaceuticals will be impossible because they will have fallen ill. Can the Minister tell us what conversations Her Majesty’s Government have had with the Royal Pharmaceutical Society to free up some of the normal professional regulations and requirements for exemption and insurance so that relatively recently retired chemists may come back to fill in the gaps that will undoubtedly be there and which will make many pharmacies ineffective because there is no chemist to dispense?

[Lord Bethell]

The noble Lord is entirely right to focus on pharmacists. I pay tribute to the important role they play in communities. Their role will be essential in the forthcoming months when enormous pressures will be put on hospitals. We will be encouraging people to avoid areas of infection. A typical pharmacy where there are two pharmacists, who might be related or even married, will clearly be under pressure. Two people working closely together are clearly an infection challenge. That is why we have engaged very closely with the pharmacy industry. The noble Lord is entirely right that the possibility of using recently retired pharmacists is being considered. Soon-to-qualify pharmacists might face early call up. Many have already been written to and there might be provisions in the forthcoming coronavirus emergency Bill to expedite the regulatory changes the noble Lord suggests.

Women: Postnatal Depression

Lord Alderdice Excerpts

Thursday 5th February 2015 Lords Chamber

[Earl Howe]

My Lords, we know there is more to be done. There are perhaps two key actions here. One is having a sufficient number of trained professionals in place—I have mentioned the increase in the number of health visitors and midwives—and the other is raising awareness of the risks and signs of postnatal depression with mothers-to-be. Extensive training is available and delivered to midwives, both during their initial training and afterwards. The programme of family nurse partnerships commenced by the previous Government is tremendously important in the follow-up stage after birth to ensure that new mothers are monitored closely.

[Lord Alderdice (LD)]

My Lords, we know that one of the very important elements in support of women in the pre- and post-partum period is the quality of the relationship between the father and the mother of the child, and that where there is a problem in encouraging that, there is frequently difficulty. Given that, is my noble friend satisfied that this element of the relationship is sufficiently addressed, appreciated and nourished in all our facilities?

[Earl Howe]

The role of the father, as well as of course that of the mother, is emphasised in all the guidance—certainly in the healthy child programme but also in the work done under family nurse partnerships, which targets the most vulnerable families. That programme provides intensive support to young first-time mothers and their babies. It explicitly involves fathers—and/or other family members as well—as long as the mother wants the father to take part.

World Innovation Summit for Health

Lord Alderdice Excerpts

Monday 16th December 2013 Lords Chamber

[Earl Howe]

My Lords, we need to hold the NHS to account by reference to the outcomes that it achieves. I do not belittle the need to spend sufficient sums of money. The National Survey of Investment in Adult Mental Health Services has indicated that reported spend on mental health services has continued to hold reasonably steady over time. I reiterate that mental health and well-being is a priority for the Government, as I hope the noble Baroness knows. We have clear indicators in the NHS outcomes framework, which will ensure that NHS England will need to focus on this area very closely.

[Lord Alderdice (LD)]

My Lords, it is extremely welcome that my noble friend has emphasised again that for the Government, under the Health and Social Care Act, parity of esteem between physical and mental health is to be maintained in this country. Perhaps I might press my noble friend a little further than the noble Lord, Lord Crisp, did. Have there been discussions between the Department of Health and DfID about DfID espousing parity of esteem for physical and mental health in its proposals, and have there been discussions with other government departments, such as the FCO, about the increasing abuse of mental health and psychiatry facilities for political prisoners in various parts of the world, not least in some of those countries with which we have good relations, including Russia?

Health: Talking Therapy

Lord Alderdice Excerpts

Tuesday 3rd December 2013 Lords Chamber

[Earl Howe]

My Lords, I agree that waiting times for talking therapies are too long, and we are taking energetic steps to address that within the bounds of affordability. In the context of the noble Baroness’s main Question, what surely matters is the quality of outcomes, rather than just the extent of inputs. We set the outcomes that we expect the NHS to achieve in the NHS outcomes framework. There are a number of outcomes in there specifically for people with mental health problems, and others, about the quality of services. It is up to commissioners to prioritise their resources to meet those outcomes for the population based on assessments of need, and we will hold them to account for that.

[Lord Alderdice (LD)]

My Lords, I entirely support my noble friend’s commitment to good outcomes, but those also require sufficient inputs. If the noble Baroness’s request for a right to talking therapy were implemented tomorrow, it would completely collapse because there simply are not enough trained therapists to provide the care that is required. What measures are the Government taking to ensure that in future there will be sufficient trained therapists to provide the parity of care for those with mental illness that is available to those with physical illness?

[Earl Howe]

I can assure my noble friend that Health Education England has it in its sights to make sure that sufficient numbers of professionals are trained in the talking therapies, and that work is ongoing.

Mental and Physical Health: Parity of Esteem

Lord Alderdice Excerpts

Thursday 10th October 2013 Lords Chamber

[Lord Alderdice (LD)]

My Lords, I also congratulate the noble Lord, Lord Layard, on achieving this substantial debate and indeed, as he himself mentioned, on the timing of the debate. He has been pressing the case for some time, and in doing so he has my support and that of many in this House. I identify myself very much with the speeches of my noble friend Lady Tyler of Enfield and the noble Baroness, Lady Murphy. I wish to touch upon many of the things that they mentioned and I strongly support others, although I will not refer to them.

As was said by the noble Lord, Lord Layard, in many ways this debate comes from the crucial decision by your Lordships’ House to press the case for parity of esteem between physical and mental illness to be included in the Bill which passed through this House. I well remember that reassurances were given, both in negotiations outside the House and on the Floor of the House, that this was not necessary. I pay tribute to my noble friend Lord Howe, who has made it very clear on a number of occasions since the Bill became an Act that it does make a difference, that it is a legal requirement, that health commissioners now have to address this question, and that others who need care can turn to it in various ways as a matter of law in this country. We must now press the case as strongly as we can. I welcome this debate because it is part of the process of pressing the case.

The noble Lord, Lord McColl of Dulwich, reminisced about his experience as a medical student, and inevitably encouraged me to think in the same way. I remember quite a different experience. As a young medical student I went to work for a psychiatrist, Dr Artie Kerr, for a number of weeks. I was enormously impressed by the way in which he could understand what was going on behind the scenes with the patient. He was able to pick up—and to help me to understand in a way that I simply had not seen at all—how sometimes the person who came along smiling was actually deeply depressed inside, and how in fact much could be done even with those people who had been ill for a long time, not least in caring for them when you could not cure them.

What an extraordinary business it is that we think that if you cannot cure someone with a mental illness you should not bother to look after them. If this was a patient with diabetes, which we cannot cure, would we say, “Ah well, we should forget about it”? Take a child with cystic fibrosis. We know that they are likely to die early, but should we say that we should not bother putting any money into caring for them? Yet if someone has a mental illness, and they are not going to get better in a short time or perhaps not at all, then caring does not seem to matter. It is all about cure. Let us not be seduced by those kinds of arguments. They take humanity out of our service, and they take humanity out of ourselves. It was that understanding from Dr Kerr which made me feel that that is the kind of work which I want to pick up on.

As a junior psychiatrist I used to spend a lot of time going round NGOs and charitable bodies, giving lectures and doing radio and television work at home in Northern Ireland, trying to get across this whole question. I remember very well doing a programme with a very senior surgeon, Professor Rodgers. He had been a surgeon all his life, and was a very eminent man. He listened to me for a little while, and then he said, “You know, I have treated many people with terminal illnesses, very painful illnesses, who were having a very hard time. Very, very few of them ever decided to end their life; some did, but very few. But I know that a large percentage of people with mental illness find life so intolerable that they want to bring it to an end. In many ways, the suffering of mental illness is so much greater than the suffering of even some of the dreadful cancers I have had to treat”. I have never forgotten that. It was a very human response, and a very real one.

One of the striking causes of mortality in mental illness is of course when people take their own life, in suicide or in self-harm that goes further. We are talking about something that really does mean a life-threatening disturbance. That is why I was commissioned, with a number of colleagues, by the royal college to produce a report on suicide and self-harm, and what we can do for patients. That report was produced in June 2010, and it was not just a matter of a few of us sitting down and thinking about it. We did a survey of a large number of members of the Royal College of Psychiatrists, and we concluded that,

“there is enough evidence to demonstrate that we are far from achieving the level of care that service users need or the standards set out in policies and guidelines. Poor assessments, relying too much on risk issues, staff unskilled in dealing with patients who harm themselves, inappropriate discharge arrangements, lack of follow-up of patients, lack of care pathways, insufficient access to psychological treatments and poor access to services for particular groups amount to inadequate standards of care that impact on the lives of service users and their families. There is a serious problem relating to the deployment and availability of senior staff, with adequate psychotherapy and psychiatry training. It is likely that because of these services and staffing defects, the majority of self-harm remains invisible until a crisis occurs, adding to human misery and to the stress on hospital services.”

The noble Baroness, Lady Murphy, pointed out that since that time in 2010 the incidence of suicide has actually increased rather than decreased. I therefore ask my noble friend the Minister if he would agree to meet with me and a small number of colleagues from the Royal College of Psychiatrists to look at how far the findings of that report have been taken up and implemented by Her Majesty’s Government since then and how far they have not, and to explore how some more progress might be made on the findings of that report.

While something dramatic such as self-harm or suicide is clearly a crisis, there are all sorts of ways in which mental disturbances differ from each other. This is not a homogenous group of people with a homogenous group of disorders, which is one of the reasons why we run into problems. On the physical side we are very aware of the difference between symptoms and a disorder. If I run up the stairs to the Principal Floor I will probably be breathless; I am not terribly fit, you see. That is a reaction to physical exertion, but it is not a sign of illness. It is a sign of unfitness, but not a sign of illness. However, if I am sitting on the Bench here and I become breathless, that is wholly another matter.

There are many ways in which we experience psychological symptoms. It always seems curious to me that we accept that we will all have physical illnesses, mild and more severe, during our lives, yet we pretend to ourselves that we will not have mental and emotional disturbances—every single one of us, not just the ones who have to be referred for treatment. However, many of the emotional reactions that we have are not a sign of illness or disturbance. If someone is down and depressed and is not sleeping very well three weeks after the death of their spouse, that is not a sign of illness; it is a sign of an appropriate reaction to a bereavement. If, three years later, they are in the same state, that is another matter. However, we have to differentiate those people who can get better with a little help from their family and friends and whose condition does not need to be medicalised, as well as those who suffer from relatively moderate disorders, from those who have very severe disorders, as the noble Baroness, Lady Murphy, pointed out. It is clear that if we do not do that, we will be so swamped that it will be impossible to deal with the problems. What will happen is that those with the more severe illnesses will end up being set to the side because they have illnesses from which it is difficult to get better. That is a very serious problem for us.

I should like to believe that we have begun to think not only about treating the illnesses but about how to prevent them. We are clear that government policy should say that we should not smoke, drink too much or eat too much and that obesity needs to be addressed. However, what about bullying behaviour in government departments? It sometimes almost seemed to be a policy approach that the way to increase productivity was to drive people into the ground, and I have absolutely no doubt about the adverse mental health impacts of that. Surely preventive health plays a part in the way that we approach things in government and set as an example to people outside government.

Worst of all is the feeling that somehow things are getting worse—that we are taking less of an interest in certain areas. I shall give your Lordships one example and, from that, pose a question to my noble friend. In the early 1960s, a chair of mental health was created at Queen’s University in Belfast. For the next 30 or more years, psychiatry and mental health was developed as a crucial component of the training of young doctors in Belfast. There is now no professor of psychiatry or mental health in Belfast. Massive amounts of money go into cancer research but there is not even a professor of mental health. Will my noble friend approach the GMC and ask it to insist that no medical faculty trains young doctors without having a professor of psychiatry in its medical faculty? It seems a very simple thing to ask.

NHS: Health and Social Care Act 2012

Lord Alderdice Excerpts

Wednesday 9th October 2013 Lords Chamber

[Earl Howe]

The noble Lord makes a good point. There is, I think, a desire on everybody’s part not to see competition result in a race to the bottom on price. That is why we have specified that commissioners must make clear what standards they expect and apply those consistently to whoever is tendering for the service in question at a price which reflects a fair value. We believe that the current rules protect the NHS but also protect those bidding. I emphasise that competition will not be pursued as an end in itself; it will be pursued as a means to drive up quality.

[Lord Alderdice (LD)]

My Lords, it is quite clear that there are certain kinds of services that benefit from being grouped together and provided by large providers who can do so economically but to a high quality. However, there are other services that are better provided locally by people who know the circumstances and are often working in relatively small charitable bodies; for example, in the mental health sector. It is very difficult for these to tender in the way that larger companies can. Can my noble friend give me some reassurance that the Government recognise this dilemma and are trying to find ways in which smaller, local, charitable providers in certain areas can be protected, facilitated or encouraged, so that we are not simply taken over by larger corporations, which may not be in the best interests of patients?

[Earl Howe]

My noble friend makes an important point. I think that it is common to all sides of the House that charities and social enterprises play an important part in providing NHS care. They have done so for many years, and give patients more choice of where and how they are treated. We have a set of rules which, at least in theory, should protect those groups of providers. If a commissioner fails to take account of providers who are capable of providing a service and simply, for example, rolls over an existing contract, then it is open to the provider in question to complain to Monitor, which will be the adjudicator of any anti-competitive conduct.

Health: Anorexia

Lord Alderdice Excerpts

Monday 25th February 2013 Lords Chamber

[Lord Alderdice]

My Lords, I express my appreciation for the noble Lord, Lord Giddens, obtaining this debate. I note that there have been a number of debates on this issue; there was a debate recently in Westminster Hall at the other end of the Building. It is something in which I have been interested for some time. It is almost 30 years since I first published a paper on anorexia nervosa. At that stage I was of course interested in the psychological aspects of things: in individual and family therapy, and cognitive behavioural therapy. The papers I was publishing were on zinc, trace elements and gastro-intestinal hormones in anorexia nervosa, trying to see if we could understand a little better this devastating disturbance and the other associated eating disorders to which the noble Lord has referred.

Of course, as the noble Lord rightly says, these disorders did not appear in the past century. In fact, the first description of the disorder was in this city by Doctor Morton in 1689. He described a patient he had treated five years earlier: a young lady who had a disorder if this kind and died after a few months. The name itself was described by William Gull in London in the late 1800s. It is not a recent phenomenon, but it has become much more pervasive.

What is really striking looking back over the past 30 and more years is how little has changed except for the prevalence of the disorder. Most of the ways we have of understanding and treating these disorders have not changed terribly much. We have not really come much closer to understanding in an evidence-based way what we are dealing with. We can see some of the resultant phenomena. I came to the conclusion with gastro-intestinal hormones, for example, that most of what we were seeing, which was not very clear anyway, was probably consequential. It is clear that when a young person’s—or even an older person’s—body weight gets down to a certain level, their capacity to judge their body image changes. They become impervious to any kind of psychological intervention. It is necessary to get their body weight up to a certain level. In the case of young women, their periods start to return and their thinking begins to change. This is not simply a psychological phenomenon. It is not simply a biological phenomenon.

As the noble Lord, Lord Giddens, has also indicated, there are also sociological aspects to this, which we can think and postulate about. I guess we do that a lot in your Lordships’ House. One of the difficulties is trying to ensure that we have research that takes us forward in understanding these things in a scientific way. That is one of the reasons why I was a little disappointed when my honourable friend Tessa Munt asked of another honourable friend, Paul Burstow, who was the Minister in February 2012, what the Government’s guidelines were for the prevention of eating disorders. What targets exist? What is the departmental budget for the prevention of eating disorders? The answer was that there are no specific targets in respect of the prevention of eating disorders. Nor has the department set aside a specific budget.

I find that disappointing because it seems clear to me that after decades, during which a good deal of research has been done, mostly in specific areas—people will take a biological approach or a psychological approach and a few perhaps even will take a sociological approach, although not very many—it is very difficult to get a multidisciplinary research project put together without substantial backing from the Government, a major foundation or whatever. That is why I am a little disappointed that resourcing does not seem to be coming forward from the department. I hope that my noble friend the Minister will be able to say that that is not true and that resourcing is available.

I am disappointed that it has not been possible to put together the kind of multidisciplinary approach to research, a bio-psycho-sociological approach, which might take us a little further forward. As the noble Lord has said, this is a difficult problem to get people out of and to understand. It has proved to be a very difficult problem on which we can make any progress at all. The figures tell us that it is getting worse.

Department of Health: Budget

Lord Alderdice Excerpts

Thursday 6th December 2012 Lords Chamber

[Earl Howe]

My Lords, we did, as the noble Lord would expect, look at the anticipated surplus this time last year and we channelled an extra £150 million into social care then in the near-certain knowledge that the department would generate a surplus during the year. However, as he will know, it is an inexact science to predict in December what the outturn will be in April, and one has to be prudent at that stage.

[Lord Alderdice]

My Lords, my noble friend gave a reassuring Answer a week or two ago about the balancing of expenditure and resources between mental health services and physical health services within the NHS. Is it possible for my noble friend’s department to look to the possibility of any surpluses in the future being used to achieve greater parity between mental health services and the rest of the NHS, given the decisions made in your Lordships’ House regarding the Health and Social Care Act 2012 and the mandate for the NHS Commissioning Board that has flown from it?

[Earl Howe]

My noble friend makes an extremely important point. He will know that the Government have made it clear that mental health problems should be treated as seriously as physical health problems. That commitment has now been made explicit in the Health and Social Care Act 2012. As he mentioned, the Government’s mandate to the NHS Commissioning Board explicitly recognises the importance of putting mental health on a par with physical health. It tasks the NHS Commissioning Board with developing a collaborative programme of action to achieve that and it will be held to account accordingly.

Health: Mental Health

Lord Alderdice Excerpts

Wednesday 21st November 2012 Lords Chamber

[Earl Howe]

My Lords, as the noble Baroness made clear, the NHS constitution sets out that patients have the right to drugs and treatments that have been recommended by NICE for use in the NHS if their doctor says that they are clinically appropriate for them; that includes talking therapies for certain problems. The mandate to the NHS Commissioning Board is clear about everyone who needs mental health services having timely access to the best available treatment. The NHS will be expected to demonstrate progress in achieving that by 2015, as I mentioned. For many patients, there are few better therapies than talking therapies. Given that the board must deliver those outcomes, the rest follows.

[Lord Alderdice]

My Lords, I will press the Minister further on this. In his response to my debate on mental health on 8 October, he undertook to write on a number of issues. True to his word, as we have come to expect, he wrote a long, substantial, constructive and positive letter in which he discussed psychological therapies being available for disturbed people. I want to pick up on what the noble Baroness has said about schizophrenic disorders. There is a tendency for people with the schizophrenias simply to be given medication and social management. There are psychological treatments—family therapy and others—that are appropriate. Can my noble friend ensure that those who suffer from the schizophrenias will also receive appropriate psychological therapies and not simply be abandoned to medication and social management?

NHS: Mental Health Services

Lord Alderdice Excerpts

Monday 8th October 2012 Lords Chamber

Tabled By

[Lord Alderdice]

To ask Her Majesty's Government how they propose to strengthen the provision of mental health services in the National Health Service.

[Lord Alderdice]

My Lords, the noble Lord, Lord Layard, and his colleagues at the Centre for Economic Performance produced an excellent document in 2006, The Depression Report. This important document pointed out that, within the community, a massive amount of distress was caused by depression and anxiety. They were a major form of deprivation of normal life—one which was going largely untreated for the majority of patients. They invoked huge economic cost to those concerned, to their families and to economic life in the country. He and his colleagues pointed out that there were treatments available at that time and they were not incredibly costly or unnecessarily long-term.

Therefore, the report recommended a substantial investment in the training of therapists in NICE-approved training, working in teams and supplied with centrally commissioned funding. Over a period of seven years, this would achieve a major change in providing psychological therapies for people suffering from depression and anxiety. This was a very important report, but it was also an effective one, because based on that—and with much other work—the noble Lord, his colleagues and others who supported him were able to persuade the Government to make a significant investment at the time and to press for substantial changes.

Even at the time, I was a little anxious that the focus of this whole programme to increase access to psychological therapies was on cognitive behavioural therapy and some other therapies approved by NICE. One of the reasons for that was not that I had any kind of crib about those approaches to therapy, but because it seemed to me that they were relatively new and espoused with a degree of evangelical zeal. One of the things that we do know, after a long period, is that every new therapy that comes in—when it is passionately pursued by committed people—very often shows itself to be effective with patients. Then, after a period of time, it is maybe not quite as effective: not because it is not a useful therapy or a good approach, but because it is probably the case that most of these approaches to therapy, given the right therapist—the person with the right personality and training—the appropriate patient and the development of a therapeutic relationship, can be substantially effective. With the wrong personality of therapist, the wrong personality of patient and the wrong problem, they can make the situation much worse. So we know, for example, that if we use short-term therapies for people with certain kinds of personality disorders, it can make the situation much worse rather than better. Those are patients who require a longer-term approach to therapy and often a multidisciplinary team bringing various different kinds of skills.

I am not terribly surprised now to find, for example, that although the Swedish Government spent almost £200 million on training therapists and providing services that were almost exclusively CBT—other kinds of therapy were pretty much set aside, which was not the case with IAPT, to be fair—they began to conclude, as was published recently in the major Swedish social work journal, that this was not necessarily the way forward and that it was the therapeutic relationship with a patient that was important. That is not a criticism of that approach to treatment because the same criticism could be made of many others. It simply is to say that all the time we should continue to develop our understanding and evidence base. We cannot assume that when we have demonstrated something, that is it and we can put it to bed, forget about it and not explore it any further. We need to keep working at it.

It also demonstrates that psychological approaches of various kinds are effective, sometimes remarkably effective. However, it has to be the right treatment, the right training, the right person over the right period and so on, which requires a lot of work and a multidisciplinary and multimodal approach. It requires a number of different approaches to therapy. I mention that at this early stage because I always want to get that out of the way.

One could make certain criticisms but the report had a tremendous effect. It jolted the Government into starting to provide significant amounts of money for training, for bringing people forward and for valuing psychological therapies. Therefore, when the noble Lord, Lord Layard, contacted me earlier this year and said, “John, we have another report coming out”, I was very excited because I knew that the quality of the report would be high, the argument would be persuasive and that it would be done to improve things for our patients, which is the important thing.

When the report was published in June, I was not in any way disappointed. It was all those things. It was concise and clear, and it pointed at the problem in stark terms that many of us who have worked in this area for years found refreshing. Basically, it made the point that half of all illness is mental illness, which was not a surprise because we have always known that. It has a serious degree of morbidity. People’s lives are hugely damaged by mental illness, and there is enormous misery for them and their families. There is a huge cost but there are ways of dealing with these things. In the report, the noble Lord and his colleagues did not deal just with depression and anxiety. They dealt with the whole raft of mental illness, although not particularly with things such as dementia, other more organic disorders and drug and alcohol addiction, which are also important and fall within the wider group.

I was very keen for your Lordships’ House to find an opportunity as soon as possible to ask the Minister what Her Majesty’s Government’s response is to this report, which is the main burden of my remarks. I think that the report is clear and it marks up a number of issues and problems. I am very proud and pleased that the coalition Government have been prepared to give £400 million to increasing and developing access to psychological therapies. However, one of my anxieties is that I keep getting reports that that money is being substituted, and that some psychological therapy services are being closed down and IAPTs are being increased, rather than that IAPT money is coming in. We do not know whether it is adding to the services that are available.

Places such as the Maudsley, St Thomas’, Forest House in Walthamstow and Camden Psychotherapy Unit have provided well trained and good services. It is not a matter of cost because, in some of these services, the therapists coming in are good, well trained and well supervised people who provide therapy for nothing or for very small amounts of money. But it is easier for commissioners to commission one large organisation to provide one approach to therapy, rather than to pick up those who have very often provided all sorts of different approaches to therapy in the communities.

After all the things we went through because we want to see a change in the approach to commissioning, I was particularly sorry to hear that some of the new commissioning groups are simply saying, “We are going to carry on the way the previous commissioners were carrying on and we are not going to change”. If that is true, it is extremely disappointing. I seek reassurance from the Minister that he will monitor this; that he will make sure that the money is not substituted and is extra money for psychological therapies; that it is for the range of therapies; and that there is an understanding that short-term therapies—for example, for people with personality disorders—are sometimes counterproductive. We need to create long-lasting major change for these people because they are very damaged and need input over a period of time. If we do not do that, they will cost a lot more through the criminal justice system. There will also be a transgenerational transmission of their disorders, which we will need to take into account whenever we think about the costs to the community. We need different approaches to treatment that are suitable to these people.

My concern is not about just the therapeutic relationship with people in outpatient therapy. I have been very disturbed to learn that in places such as Rampton, Broadmoor and Ashworth, patients increasingly are locked up at night in wards because there are not enough staff. That is not managing the relationship. I increasingly find reports of young doctors who see a patient only once. The patient is checked in and in no time the patient is out. The young doctor does not even learn how to develop the professional relationship. Indeed, there are managerial relationships which are not very professional and are based on no evidence that they bring a positive outcome in the running of services. If we are talking about an evidence base for the therapy, we need an evidence base for some of the management approaches that have been undertaken, which are clearly and demonstrably not working.

In September, at our party conference in Brighton, I was very pleased that the report from the noble Lord and his colleagues, and the recommendations from it, was warmly and overwhelmingly supported in a motion to the conference. I want warmly and overwhelmingly to support them. There will be some issues, which we will need to explore, including the recommendation that the GPs should get more training in psychological therapies. That is absolutely right but perhaps it should be not only through IAPT teams. Perhaps there should be a bit more of an emphasis on the idea that there might be a range of therapies available.

I am hugely encouraged that we are seeing some espousing of this by the academic community. I trust that the £400 million will be extra money and that it will be added to. I know that the Minister is sympathetic to this but I hope that he will give us a little more than sympathy and reassurance. I hope that he will be able to encourage us as we see this developing over the coming months and years.