Psychosis: Early Intervention

Baroness Berger Excerpts

Thursday 15th March 2018 Westminster Hall

[Norman Lamb (North Norfolk) (LD)]

I beg to move,

That this House has considered access and waiting time standards for early intervention in psychosis.

It is a great pleasure to serve under your chairmanship, Mrs Moon, for what I think is the first time. I thank the Backbench Business Committee for facilitating this debate on an issue of real importance and something I care about a lot. I will start with the origins of early intervention in psychosis and then raise my specific concerns about the progress made under the Government’s programme.

The approach dates back to the 1990s. In 1999, the Labour Government decided to give a significant national push to the development of early intervention in psychosis services. There was a mental health policy implementation guide of that date, and at that time the service was to focus on those aged 14 to 35, the years when psychosis was most likely to emerge. Once an individual started their treatment, there was to be a three-year programme. Critical to that was small case loads, so that the professionals in multidisciplinary teams could work closely with the individuals involved. It also involved family interventions. In a 10-year period, the national case load grew to 22,500 for what was widely seen as a valuable innovation.

The National Institute for Health and Care Excellence review of psychosis and schizophrenia in 2014 concluded that early intervention services,

“more than any other services developed to date, are associated with improvements in a broad range of critical outcomes, including relapse rates, symptoms, quality of life and a better experience”

for service users. I will return to that later, but an excellent annual report by the Southern Region EIP programme—for the south of England—specifically highlighted the impact on employment rates. When these services have proper investment, people who experience a first episode of psychosis can often be got into employment or education at far higher levels that has traditionally been the case with generic mental health services. That is an enormous prize to be won, when we think about quality of life and sense of self-worth, and indeed the cost of the condition to the state—so, lots of praise for the impact of early intervention services.

The Schizophrenia Commission said that early intervention services were the “great innovation” of the last 10 years, referring to multidisciplinary working, recovery ethos, co-production, working with people with the condition and achieving high standards. Professor Louis Appleby has described the service as the

“jewel in the crown of the NHS mental health reform because…service users like it…people get better”—

that is important—and

“it saves money”,

which is also critical.

On that point, we know from analysis that for every £1 properly invested in early intervention in psychosis, there is a return of £15 over subsequent years. Of course, one of the complications is that the return is not just concentrated in reduced use of the NHS, but comes through getting people off benefits and into work, bringing in tax revenues and reducing the number of people who end up going through the criminal justice system. For all those reasons—the impact on individuals and the extraordinary return on investment—this seems like a very good thing to do. However, as the NHS’s finances started to get tighter, there was clearly disinvestment in many places—it varied around the country, but it was happening.

My insight, as Minister responsible for mental health from September 2012, was that two particular elements of the way that the NHS works end up massively disadvantaging mental health. First, there are a set of politically demanding access standards in physical health, such as the four-hour A&E standard, the cancer waiting time standards and the 18-week referral to treatment standards. I do not know if it still happens, but in my time at the Department of Health, every Monday morning all the great and the good of the NHS sat around the Secretary of State’s table with a spreadsheet for every hospital in the country, looking at performance against those waiting time standards—in physical health. There was nothing for mental health—a complete imbalance of rights of access.

Then there is payment by results, which is actually payment for activity. It means that when patients get referred to an acute hospital, that hospital receives more income. There have been adjustments and reforms over the years, but the basic principle of incentivising activity in acute hospitals, which is not matched in mental health, combined with those exacting access standards, puts enormous pressure on the system to drive people into acute hospitals to meet those standards. That has the effect of sucking money into acute hospitals. Even during the last five to seven years of tight finances in the NHS, income for acute hospitals has continued to increase, but income for mental health and community services, which do not have those financial incentives, has stayed level or, in places, decreased.

I felt we had to start addressing those perverse incentives that were disadvantaging mental health, which amount to discrimination against people who experience mental ill health. Why should the treatment for someone who experiences psychosis be in any way inferior to the treatment of someone suffering from cancer or any other physical condition? In 2014, we decided across government to publish a vision called “Achieving Better Access to Mental Health Services by 2020”, a joint publication by the Department of Health and NHS England. The vision was to achieve comprehensive maximum waiting time standards in mental health by 2020—if only. The plan was to start with two standards: a six-week standard for access to the IAPT—improved access to psychological therapies—service and a two-week standard for early intervention in psychosis.

Critically, this was not just a two-week standard. When the Government report on whether they are meeting the standard, the focus tends to be on whether more than 50% of people start their treatment within two weeks, which was the standard set at the start. However, the standard was in two parts: to start treatment within two weeks and then to have access to the full evidence-based, NICE-approved treatment package. I will focus on that element because, depressingly, evidence shows that the system is falling far short of what it should be doing.

I want to focus on a freedom of information survey conducted over this financial year to try to establish the position across the country, looking not just at how long people wait but, critically, at whether they get access to the full evidence-based treatment package. The evidence that emerges from that survey is deeply disturbing. First, only 29% of trusts across the country stated that they were meeting the full NICE-approved, evidence-based treatment package. That is 29% on a standard that the Government say is being met. It is not being met. Even 29% is generous, because within that I think there were two trusts that were delivering the service only up to the age of 35, whereas the standard says that people up to the age of 65 should be included. Across the country, people are simply not getting access to the evidence-based treatment that we know works and delivers such an extraordinary return on investment.

I suppose I would put it this way. Can we imagine a cancer service saying to patients, “We’ll give you half the chemotherapy or radiotherapy treatment,” or, “I’m sorry, but there are no professionals available to deliver this part of your treatment”? There would be an outcry. It would be impossible for the Government to get away with it. The Daily Mail would be apoplectic. We know that the result would be that the standard would be met, one way or another—but here, day by day across the NHS, this standard for mental health is routinely being missed in a wholly unacceptable way.

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

I thank the right hon. Gentleman for his important speech and his comments. Does he agree that there is a particular challenge in mental health, in that, in the wake of the Health and Social Care Act 2012, parity of esteem is enshrined in law, and we should be not just aspiring to, but achieving equality for mental health? This is just another indicator of how far we are from achieving that goal.

[Norman Lamb]

I totally agree. The 2012 Act is clear that there should in effect be equal treatment between mental health and physical health, but the evidence shows it is not being delivered. I fully understand that it takes time to get there with a new programme, but it is the way it is being implemented that gives me greatest cause for concern. I will focus on how we are falling short of that standard.

In the south region, there is a brilliant programme; it is always important in these debates to recognise that there are sometimes areas of fantastic practice that should be applauded. In the south of England, an amazing woman called Sarah Amani is the programme manager, and there is a full implementation programme. My argument to the Minister is that what is happening in the south should be happening everywhere. The programme produces annual reports, so it is completely open and transparent about the progress it is making and the obstacles that lie in its way.

I should have mentioned that our survey showed that across the country not much more than 50% of the total amount that NHS England says must be invested per patient is being spent per patient on delivering the service. If we are only spending a bit more than 50% of the amount we need to spend, it will fall short. What NHS England in the south is doing is admirable. It highlights that in many areas things have improved over the last year in its region, because it is driving that, but it also says:

“There is four-fold variation between the most and least funded EIP teams in the South of England.”

A fourfold variation would never happen with the cancer service. Furthermore:

“None of the providers have investment recommended to provide a NICE concordant package of care”.

In the best region of the country, no provider is meeting what it needs to spend to deliver the full package of care.

On workforce, the report says:

“Recruitment has been in part hindered by lack of extra investment and compounded by a national reduction in the number of qualified staff, particularly nurses”.

On intelligence, it says:

“Although all mental health providers use Electronic Health Record (EHR) systems, the majority (13 out of 16) of providers have yet to automate reporting, resulting in clinicians having to manually troll through whole caseloads for multiple data requests.”

In this day and age, that should not be necessary. There should be a system across the country to enable us to monitor performance against that important standard. When we go through the elements of the NICE-approved treatment package, such as cognitive behavioural therapy for psychosis, across the best region in the country there is enormous variation in the amount of therapy available to people. Some trusts provide what is required, but most fall short.

If we then look at comprehensive physical health checks, there is a target of 90%. We know that people with severe and enduring mental ill health die 15 to 20 years younger than other people, and that part of that can be addressed by having physical health checks. There is a Commissioning for Quality and Innovation standard established for 90% of people with severe and enduring mental ill health to have physical health checks. Across the south of England it is 56%, not 90%. Individual placement and support is a critical element of getting into work, with loads of evidence to support its effectiveness; 30% in the south of England have access to individual placement and support. Going back to what I have said, we must look at the results that flow if we make the investment. It is not only morally wrong but economically stupid to avoid making that investment.

I come now to the evidence on outcomes. The programme can show that where it does the work, hospital admissions are substantially reduced. The evidence is clear for anyone looking at the report to see. The report then looks at employment and education, where it is achieving substantially better rates of employment than generic mental health services, at 46%. Fascinatingly, it even analyses the relationship between investment and outcomes, so it can show that the more we invest in these evidence-based interventions, the better the outcomes. What a surprise: more people get into work, more people get into education and lives are transformed.

The report then talks about securing investment. Bear in mind that I am not quoting a politician but an internal document, led by the Oxford Academic Health Science Network:

“If the Five Year Forward View commitment of £40 million for EIP teams in 2015-16 had been honoured, EIP teams in the South of England would have seen a total growth in budgets of around £15 million. Instead, in 2015-16 the South region EIP teams saw a meagre increase of £3 million.”

That is £3 million instead of £15 million. The report continues:

“Between 2016-18, this trend of lack of investment has continued with a £3.5 million increase in EIP team budgets compared to the £15 million that was expected. Of the 16 providers delivering EIP in the South of England, none have the £8,250 investment per patient recommended to deliver a NICE concordant package of care. The South of England has a poor track record of investment in EIP services”.

That is the best region in the country. It leaves me feeling frustrated that such a prize—such an opportunity—is being squandered through lack of investment and lack of effective implementation.

I then look to the midlands. I have received an email from someone who is working on early intervention in psychosis in the west midlands, which reads as follows:

“There is wide variation in service quality, data reporting, outcomes, resourcing and resource allocation. This has not been made public, presumably because it is politically inexpedient to do so…Many trusts have chosen to disband EIP teams as a cost saving exercise (in Nottingham), or to allow caseloads to rise from 1:15 to 1:30”—

the whole essence of this approach is low case loads, so that people can get the personal attention that they need—

“not provide enough of the NICE mandated therapies, to not appoint psychologists or enough support workers, leading to expensive but ineffective teams…There is currently no governance or accountability in place, which enables the triangulation of proper resources, recommended service levels and outcomes.”

No governance or accountability in place across the midlands. That leaves me totally bewildered. Would this ever have happened when they implemented the cancer standards in the last decade? Of course not. Yet that is what has happened.

“There are systems in place in the north…and in the south…to provide the mechanism by which the accuracy of data, resourcing, services and outcomes can be verified and addressed…The Midlands region of England (west, central, east midlands, and East of England) are the only areas without any established regional development programmes and therefore have no reliable mechanism to prevent the inexorable decline of standards in EIP.”

That is from the frontline and, it seems to me, ought to be taken extremely seriously.

In a presentation given recently in February, in the west midlands, a west midlands clinician said:

“We are really struggling to provide an EI service that meets the NICE quality standards. Most of the focus of the Trust has been on meeting the two week access standard, which we have done most of the time. We did get some additional money, but it was non-recurring. Caseloads are way above the national average and we are really struggling”.

It then goes through the various elements of the NICE-approved programme.

“Referral rates are very high and we are discharging people sooner than we should.”

That should not be happening in a programme that the Government ought to be really proud of. It is a gem that ought to be nurtured and developed in order to get the very best from it.

When we published the survey that we did earlier this year, the response from NHS England was deeply disappointing. The official was quoted as saying:

“10,000 people each year are now receiving treatment through the early intervention in psychosis programme, with over three-quarters of patients getting treatment within two weeks…The analysis inevitably gives only a partial and dated picture of progress in these services.”

Well, I do not think that public bodies should be making misleading statements like that, because the analysis was full and complete across the whole country. It was not dated in any way. But this quote from NHS England—an anonymous quote—was designed to discredit the analysis. Rather than discrediting the analysis, it seems to me that a public body should be acknowledging the problem and addressing how it will try to solve it. This sort of denial approach is unhelpful. I wrote to the UK Statistics Authority, because I think it is inappropriate for public bodies to respond to analyses in that way.

Before I finish I want to deal with some asks of the Government. This is part of the five-year forward view. The Government have stated that it is a clear priority, so I want the Government to make it a priority. I want the Government to look at the implementation of this programme and to recognise that in some regions, nothing is happening to drive the implementation of these national standards. Personally, I think that it is intolerable that someone with psychosis in Dudley, in the west midlands, gets a raw deal compared with someone in the south of England, but that is what is happening now, because NHS England has no implementation programme in the west midlands, or across the entire midlands, including my own region—the East of England.

First, it needs sufficient investment. Given that there is a return on investment of £15 for every £1 spent, my plea to the Government is to make the investment because they will see a return on it, and benefit from improved employment rates and everything else. Secondly, address the staff shortages that are clearly—according to our survey—holding back services all over the place. It really means that Health Education England needs to create a credible plan to address the workforce shortages in early intervention in psychosis services, so that no area falls short because it cannot recruit the right people to deliver the service. Again I ask, would it happen in cancer? Of course not.

Thirdly, end the outrageous age discrimination. A quarter of the trusts that responded to our survey still have a limit of 35 on the service that is delivered, which means that anyone over the age of 35 is not getting access to the evidence-based treatment programme. Fourthly, get back on track with the two-week standard. We are also seeing that even though the standard is being met, the performance is deteriorating. The figures for early this year are worse than the whole of last year, suggesting increasing pressure on services around the country. That is important for the Government to address as well.

Fifthly, the standard applies not only to people who experience a first episode of psychosis, but to people who are at risk of psychosis; but many services simply say, “We don’t deliver a service to those people.” Of course, that is the best early intervention. If we can intervene before the psychosis has occurred, everyone benefits massively, particularly the individual concerned. In many areas, though, there is simply no service, despite the standard being very clear about what is required. Sixthly, the Government need, as I have said, to fund implementation programmes for every region, modelled on the plan and programme in the south of England, so that everywhere gets access to the same level of service.

Finally, our vision of comprehensive maximum waiting time standards in mental health by 2020 was published not just by Lib Dems, but by Conservatives. It was the Government’s vision. The point of it was to end such discrimination in a publicly funded service. It is not justifiable to have rights of access to treatment for physical health services, but not for mental health services. Why should people be left waiting, sometimes for months on end, for access to treatment? Treatment should be based on evidence and clinical need. But that vision, it seems to me, although included in the “Five Year Forward View”, is not being funded. There is no resource available to implement it. So my plea to the Government is: return to that vision. It was a good vision in 2014.

I will end by making this point: nothing that the Government could do would have a bigger impact on the wellbeing of our communities than to end the under-investment in mental health services. The best example, where the evidence is at its strongest, where you can reduce the flow of people into long-term support from secondary mental health services, is early intervention in psychosis services. There is an enormous prize to be had, but it needs investment and attention, which is lacking at the moment.

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[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

It is a pleasure to serve under your chairmanship, Mrs Moon. I congratulate the right hon. Member for North Norfolk (Norman Lamb) on proposing this debate to the Backbench Business Committee—a proposal for which I was a signatory—and securing this important and timely discussion.

The right hon. Gentleman and I have shared many platforms in supporting joint campaigns, and we have debated often the state of our mental health services. We have come to expect from him a level of forensic detail, commitment to improvement and genuine compassion for those with severe mental illness, and today he has not disappointed. We may have very small differences in approach or policy, but he and I share a big-picture commitment to world-class mental health services in this country; to genuine, tangible parity of esteem—real equality—between physical and mental health services; and to a transformation in the way that we view mental illness, talk about mental illness and treat those with mental health conditions.

As with many other forms of mental illness, all the experience and evidence point to the fact that the best time to intervene in cases of psychosis is as soon as possible. The work of Professor Patrick McGorry in Australia and proponents of early intervention in the UK clearly shows that early intervention can have a huge impact on the health of the individual patient, with more chance of them living with conditions in a managed way and ultimately more chance of their recovery.

I echo some of the right hon. Gentleman’s points about the benefits of getting back into employment and the importance of accessing individual placement and support. That is a well-evidenced measure that has already made a tangible difference to many people living with mental ill health. I will reflect on the experience in my area, Merseyside, where Mersey Care provides the majority of mental health services, including early intervention in psychosis. It did an audit of all the patients that it looks after in both the community and in-patient services. It is staggering that just 3% of their patients are in any form of employment. If we compare that figure with people in physical health services, the inequality—the massive disparity—when it comes to mental health is a great concern. That strikes at the heart of the issues that we are discussing.

It should not surprise hon. Members that the earlier we treat any condition, be that a mental or physical health condition, the more likely we are to get a positive result. In terms of system reform in the health service, early intervention clearly fits into the mantra of prevention being better than cure. I have said it before, but I will say it again: if people are not convinced of how important this is by the moral and social reasons, the financial and economic consequences of not contending with mental health sooner should be enough.

For the NHS to be sustainable in the long term, when it will increasingly have to contend with lifestyle-related diseases, we need a seismic shift from treating diseases and conditions when they present in crisis in their most acute forms to a system that allows us to detect them in their earliest stages, to manage them with early interventions and to do everything to avoid certain conditions in the first place, although that is not always possible. That is as true of mental illness as it is of cancer, cardiovascular disease and coronary heart disease.

The issue is not just health outcomes, but the impact that psychosis has on the totality of an individual’s life and their opportunity to be involved in education, employment and training, to maintain relationships with family and friends, to own a home or maintain a tenancy, to be able to go to work and to not be in our criminal justice system. Those outcomes have far-reaching and long-term consequences that are not contained solely within the Department of Health and Social Care, although a Health Minister will respond to today’s debate.

With that in mind, in February 2016, the Labour Front Bench, including me as the then shadow Minister for Mental Health, welcomed the inclusion of the access and waiting time standard for early intervention in psychosis in “The Five Year Forward View for Mental Health”. The commitment was that NHS England should ensure that by April 2016, 50% of people experiencing a first episode of psychosis had access to a NICE-approved care package within two weeks of referral, rising to at least 60% by 2020-21.

It is important to reiterate that laudable target and ambition. It was modest, but it was an important first step and it was welcomed across the House, so it is with heavy hearts that we review progress since then, and realise that the system is failing to reach the target stipulated in the “The Five Year Forward View for Mental Health”.

Once again, we should recognise the detailed work of the right hon. Member for North Norfolk in unearthing the emerging picture from across the country. Every Minister’s worst nightmare is the ex-Minister armed with the tools of freedom of information requests and parliamentary questions, and who knows the darkest secrets at the heart of the Department.

We now know that the access and waiting time standard for early intervention in psychosis is not being met. Too many providers cannot offer the full NICE-approved package of care. There is variation across the country, with, as ever, the poorest people in the poorest parts of the country receiving the poorest levels of service. That real inequality is a social justice issue.

I echo the concerns expressed by my hon. Friend the Member for Stockton South (Dr Williams) about the figures for his constituency in the north of England. The north of England commissioning region has the lowest proportion of completed pathways and the highest number of total referrals still awaiting treatment—two thirds. That should be a serious concern for us all. The inverse care law, first identified some 40 years ago, is alive and kicking when it comes to mental health services.

The latest picture published by NHS England shows that far from the steady progress we all desire, the proportion of patients in the early stages of psychosis that started treatment within the two-week target was lower in January than it was in May 2016. In the first 10 months of 2017-18, 9.1% fewer patients started EIP treatment within the two-week target, compared with the first 10 months of 2016-17.

Behind those figures, as other hon. Members have indicated, are real people who are suffering the early manifestations of psychosis, which can be extremely disturbing for them and for their friends and family. I have had the privilege of visiting a number of in-patient units, not just in my constituency but across the country, and I have heard first hand about patients’ experiences. The longer they have to wait, the greater the negative impact can be on their condition and on their chance of recovery.

The Royal College of Psychiatrists points out that if people do not receive help early enough, they are more likely to experience poor physical health, lower levels of social functioning, and poorer occupational and educational outcomes. That is a serious concern for us all, which is why we are here this afternoon.

We also have to think about what happens in the future. I am grateful to YoungMinds for its analysis of the sustainability and transformation partnerships, due out next month, which shows that less than a quarter of STP plans demonstrate an explicit commitment and clear plan to meet the EIP target for 2020-21. It is not just about what has happened in the past and looking at the results retrospectively, but about what will happen in the coming years. The Government have endeavoured to have STPs, and the EIP target should be at the heart of what they are doing. Unfortunately, it is not, despite the fact that the implementation of that waiting time target is one of the nine requirements for STPs, as set out in the NHS planning guidance.

I will turn to an area that is of particular interest to me. In the year since the birth of my child, I have been even more aware of the need to support the mental health of new mums. Around 85% of new mothers experience some change in their mood, and for around 10% to 15% of them, that might mean more serious symptoms of anxiety and depression. More than 1,400 women experience post-partum psychosis each year in the UK, which is between 1 and 2 in every 1,000 mothers. I was struck that a woman is between 30% and 40% more likely to experience a period of psychosis in the year after childbirth—more than at any other point in her life.

Post-partum psychosis can take many forms, including hallucinations, depression, delusions and mania. It can be extremely distressing for mothers, their partners, their wider families, and of course, the child. I have had the opportunity to visit two mother and baby units across the country to hear from mums first hand. The condition does not discriminate. It can affect women of any background, colour and income, and it can have serious and far-reaching consequences.

The National Childbirth Trust, the Maternal Mental Health Alliance and others have specifically highlighted the paucity of provision of mental health services for new mothers and the effectiveness of the six-week check in identifying the early stages of mental ill health, including psychosis. In the mix of the debate, I hope the Minister will be able to comment on that.

[Dr Paul Williams]

I, too, have read the National Childbirth Trust’s report, “The Hidden Half”. It says that despite it being a vulnerable time for women, more than half of women who experience post-natal mental health problems say that they were not asked about them by any health professional. Will my hon. Friend join me in calling for that to be added to the GP contract so that GPs routinely provide a six-week check for the mother, as part of the six-week check for the baby?

[Luciana Berger]

I thank my hon. Friend for raising that important report and the campaign, which I have considered as well. The National Childbirth Trust makes an important point about the connection that GPs have with new mums and their babies. I recall that my GP did ask me about my mental wellbeing and how I felt, but that is not the case for every mum. It is something that we should consider, along with ensuring that every contact counts when it comes to new mums and their babies—be that with the health visitor, a midwife who might come to the home or someone in the hospital. We need to look at the whole spectrum of engagement to ensure that we consider the mental health of mum and baby every step of the way.

I mentioned mother and baby units, which are incredibly important. For anyone who does not know, they are an opportunity to ensure that if the mum is experiencing a period of psychosis or another serious mental illness, they are still able to be with their child. The units offer extremely specialised care and incredible attention from clinicians, who do a remarkable job of ensuring attachment so that mums are not disconnected from their babies, even if they have to be moved across the country.

Mother and baby units are very important for recovery rates. I have asked several parliamentary questions about them, but I want to ask more in the context of this debate because of their importance to mums who experience post-partum psychosis. In January, I asked the Secretary of State, in a written question,

“how many mother and baby beds commissioned by NHS England Specialised Services in 2016/17 are (a) available and (b) in use.”

I asked that because although we know that beds have been commissioned, it is not clear whether they are available or in use. The figures that I received in response to a previous question showed a decrease of one in the number of beds available across the country since 2010. I ask the Minister the same question again, publicly, because her response in January was:

“The information requested is not available.”

I do not think that it is a difficult question to answer. In the context of this debate, it is a very important one, so I hope the Minister’s officials will provide her with an answer today. Post-partum psychosis, no less than any other kind, requires early identification and early intervention, but we are not doing enough to treat or support post-partum psychosis alongside other forms.

Let me conclude with some brief questions that I hope the Minister will address. First, what steps is her Department taking to address mental health inequalities and the waiting times postcode lottery, particularly in cases of early episodes of psychosis?

Secondly, how can the Minister guarantee that money allocated for mental health services is actually reaching the frontline in all the areas in which it is needed? There are many examples of mental health budgets being raided to pay for other parts of the NHS.

Thirdly, does the Minister agree with the Royal College of Psychiatrists that we need to improve the financial data available for early intervention in psychosis services? Without it, we cannot be sure that services are properly investing in EIP.

Fourthly, does the Minister believe that frontline mental health services have adequate numbers of staff—including psychiatrists, mental health nurses and therapists—to meet the targets set out in the five year forward view? I echo the praise of other hon. Members for our frontline clinicians, who do an incredible job under very challenging circumstances but are severely stretched, as we hear time and again. They cannot meet the workforce challenge alone.

Lastly, what steps will the Minister take to drastically improve early intervention in cases of post-partum psychosis, especially at the six-week check for new mothers, so that we can support women in the first weeks after the birth of their baby?

I congratulate the right hon. Member for North Norfolk again on securing the debate. Let us hope that our deliberations this afternoon will lead to concrete improvements and swift action from the Government to prevent unnecessary psychosis, intervene early to prevent unnecessary suffering, and help as many people as possible across the country towards a meaningful path to recovery.

[Mrs Madeleine Moon (in the Chair)]

I will call the first Front-Bench speaker at 2.30 pm.

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[Neil Gray (Airdrie and Shotts) (SNP)]

Thank you for calling me, Mrs Moon. I should perhaps have said earlier that I would take only a short amount of time in my winding-up speech, particularly as we are discussing a devolved issue. I hope that the hon. Member for Faversham and Mid Kent (Helen Whately) did not have to cut what was a very good speech short. I should perhaps have indicated to you, Mrs Moon, that I only intended to take a short amount of time, to enable everyone to get the full coverage.

It is a pleasure to speak with you in the chair, Mrs Moon, on this very important subject. I congratulate the right hon. Member for North Norfolk (Norman Lamb) on securing the debate and pay tribute to his awareness-raising and campaigning work on this important issue over a great number of years, as has been mentioned. I also commend him for his detailed and comprehensive speech and, as I have indicated, for bringing people together today in search of consensual debate, especially when we consider that the topic is health, which normally divides political opinion. On this occasion it has rather united political opinion, so I commend him for that.

The right hon. Gentleman’s powerful speech was supported by others. The hon. Member for Stockton South (Dr Williams) spoke of the stark reality that sadly faces people who do not get access to early intervention following diagnosis with psychosis. He spoke with experience and knowledge of this issue, and added greatly to the debate. The hon. Member for Liverpool, Wavertree (Luciana Berger) has also worked tirelessly for a number of years on this issue. The statistic she cited—that just 3% of those with psychosis in her area are in employment—is quite frankly staggering. She also spoke of the prevalence of mental health vulnerability for women after childbirth. For me, those two issues alone, among all the others, highlight the importance of getting this right across all areas and why we all need to do more in all areas of this country, and all Governments should do that.

[Luciana Berger]

Forgive me, but in my remarks I was due to pass on a contribution by the hon. Member for Belfast East (Gavin Robinson), who wanted it made known on the parliamentary record that there is no mother and baby unit in Northern Ireland. Although the issue is not devolved, he wanted that point about the availability of support for new mums to be made in the context of this debate.

[Neil Gray]

I thank the hon. Lady for that intervention; it is clearly important that that is put on the record.

Also, as I have already indicated, the hon. Member for Faversham and Mid Kent made a very honest speech. Her observations from her clinical experience highlighted how destructive psychosis is, so I pay tribute to her for her contribution. I hope that the Minister will respond not only to hers, but to all the points raised by right hon. and hon. Members.

This issue is important, because when the Prime Minister entered Downing Street on 13 July 2016, she listed a number of “burning injustices” that she hoped to address, in order to make Britain

“a country that works for everyone”,

among which was the injustice that

“If you suffer from mental health problems, there’s not enough help to hand.”

Clearly, such rhetoric is to be welcomed, as is the Prime Minister’s promise that parity of esteem would be introduced in dealing with mental health services in the NHS in England. However, as demonstrated in I think all the speeches today, we have not really got to the point of matching that rhetoric with actions and outcomes. I think there was a universal acknowledgement in today’s speeches that not enough is being done.

Today’s debate focuses specifically on psychosis and the waiting-time standards for early intervention in this area. As we are all too aware, mental health in general often comes with many stigmas and misconceptions attached, and that is nowhere more apparent than in relation to the subject of today’s debate. In psychosis, people experience symptoms of paranoia, and often delusional belief systems that take them outwith reality—that was covered so well by the hon. Member for Stockton South. It affects sufferers socially and in terms of their work, education and overall health. Although only a small proportion of the population are impacted by psychosis, particularly compared with other mental health issues, its impact on the individual and those around them can be devastating, and sufferers require long-term support and help to recover.

As my hon. Friend the Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron), who is herself a clinical psychologist, pointed out in a similar Westminster Hall debate in September 2016, behavioural family therapy is also extremely important. Psychosis affects not just the person who suffers, but their whole family and social circle. People can suddenly find themselves in a caring role, and research indicates that spending 10 hours or more a week as a carer can be a challenge to someone’s wellbeing.

As the subject of today’s debate and the contributions of many Members have made clear, early intervention is key to ensuring that the support and recovery process can be as successful as possible, for both the individual and those around them. In Scotland, the Scottish National party Government have made mental health one of their main priorities, and they will continue to place a high importance on mental health services. A key part of that prioritisation in relation to psychosis has been focusing on prevention and early intervention, particularly for infants, children and young people—it has already been said why that is important—who are the groups most likely to be impacted by the first episodes of psychosis.

Analysis undertaken by the King’s Fund recommended that

“Providing high-quality care to patients requires two things: first, that NHS trusts have the revenue to recruit and retain the correct mix of staff, and second that these staff exist and want to work for the NHS. Our analysis highlights that there are underlying issues with the supply and availability of key staffing groups in mental health. Investing in the skills, job satisfaction and wellbeing of our current workforce should be a priority, but we must also invest to ensure sufficient workforce capacity.”

In Scotland, the Government have attempted to address those important staffing and funding issues by increasing NHS mental health spending from £651 million in 2006-07 to £937 million in 2016-17, which has enabled the aim of placing an additional 800 mental health workers in key settings by 2022 to remain on course.

However, I am not trying to argue that there is no room for improvement in Scotland—clearly there is—and that everything is as good as it can be. Clearly, there is more that we could and should do. The Scottish Government are aware that there is room for improvement and their “Mental Health Strategy 2017-2027” has identified a number of areas where further improvements can be made. In particular, the strategy acknowledges that

“Working to improve mental health care is not just the preserve of the NHS or the health portfolio.”

Instead, improving mental health care requires improving a wide range of public services, such as education and justice, as well as addressing other important societal problems, such as poverty and employment, all of which have a relationship with mental health and a role to play in improving health outcomes.

Again, I commend the right hon. Member for North Norfolk, and I hope that the Minister, when she replies, will reflect on all the comments from the right hon. Gentleman and from others, and respond to the examples given from the frontline and to the asks that he and others from different parties have made today.

Mental Health Act: CQC Report

Baroness Berger Excerpts

Tuesday 27th February 2018 Commons Chamber

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

(Urgent Question): Thank you very much for granting this urgent question, Mr Speaker. This morning, the Care Quality Commission published—

[Mr Speaker]

Order. I am immensely grateful to the hon. Lady, but she needs to say, “To ask the Minister for a statement, etc.” She will get her full go—her full bite at the cherry—when the Minister has delivered the initial statement. That is the way it works.

[Luciana Berger]

To ask the Secretary of State for Health and Social Care to make a statement on the Care Quality Commission’s report, “Monitoring the Mental Health Act in 2016/17”.

[The Parliamentary Under-Secretary of State for Health (Jackie Doyle-Price)]

The Government welcome the CQC’s latest annual report, which it produces as part of its statutory duty to monitor how mental health providers exercise powers and discharge their duties when people are detained under the Mental Health Act 1983. We are committed to ensuring that the Act works better for patients and their families, and this is why we have commissioned an independent review led by Professor Sir Simon Wessely, which will make recommendations in autumn. We are also investing more in mental health than ever before, spending an estimated record £11.6bn this year.

We have seen that the number of detentions under the Act has been rising year on year: it rose by 2% last year and by 9% the year before that. We also know that black people are disproportionately affected. These were both driving reasons for the Prime Minister’s decision to call for a review of how the entire Act is operating. The Government have already acted when they saw that the Act was not working properly. Last year, we legislated to make it illegal to use police cells as places of safety for children under the Act, and to ensure that police officers consult health support staff before using their detention powers.

Sir Simon, his vice-chairs and the independent review’s team are consulting actively and widely with service users and professionals, and today are taking part in a major stakeholder event in Newcastle. Indeed, I welcome the fact that the CQC takes care in its report to state: “We have confidence that the independent review’s solutions-focused approach to identifying priorities, based on the feedback and experiences of people across the country, will offer a review of the MHA that has the confidence of patients and professionals.” The CQC is, of course, directly involved in that review.

The CQC’s report found examples of good practice, but we recognise that more needs to be done to ensure that people’s voices are heard and their rights respected. Where possible, we expect all patients to be involved in their care planning and that providers should consider how best to do this in the light of the CQC’s recommendations. In the spring, the review will provide an interim report identifying priorities for its work. It will then develop a final report containing detailed recommendations on its priorities. This final report should be delivered by autumn 2018.

There are problems with the Act, and we will address them, but we should remember that today no one gets sent to an asylum only to disappear within its walls. There are regular reviews, clear rights of appeal and checks to ensure that people are lawfully detained only to get the treatment they need. Our society is changing how it thinks about mental illness, however, and we want to ensure that people have as much liberty and autonomy as possible.

[Luciana Berger]

This scathing report finds that too many patients subject to the Mental Health Act continue to experience care that does not fully protect their rights or ensure their wellbeing. Some Members might have seen the harrowing episode of “Dispatches” last week, which showed scenes of a patient experiencing violent restraint at the Priory Group’s Dene Hospital. Today’s CQC report indicates that these experiences are not isolated. It shows no improvement in key areas of concern raised by the commission in previous years. It is totally unacceptable. In fact, some of the indicators are getting worse. Why is there still no evidence of patient involvement in 32% of care plans—up from 29% last year; of patients’ views being recorded in 31% of care plans—up from 26% last year; and of consideration of the least-restrictive care options in 17% of cases—up from 10% last year? This last, in particular, is a matter of serious concern. We know that the period following discharge from in-patient care is when most suicides happen. Why, then, in 24% of care plans was there no evidence that plans were made for discharging patients back home?

The report exposes the pressure on high secure hospital placements for women. One patient was in long-term segregation for over a year while waiting to access a bed. The Minister, to whom I listened closely, referred to the review by Sir Simon Wessely, but his review and report cannot provide answers to this patient or many hundreds more across the country today. Despite repeated Government promises of parity of esteem, we have seen yet another year of inaction. Does she accept that, in 2018 here in England, what is outlined in today’s CQC report is completely unacceptable, and will she tell us exactly what she is going to do this week to ensure that no patient in our country in a mental health unit is deprived unnecessarily of their human rights?

[Jackie Doyle-Price]

It is worth reminding the House why we introduced the CQC—to provide for transparent inquiry into the performance of our health services and so ensure they remain the best in the world. It is for precisely this reason—to make sure we do better—that we invite the CQC to do so so honestly and take any criticism arising from the transparent scrutiny that characterises this and all its reports. We recognise that we can always do better. The duty of candour in the NHS under this Government means that we will step up to the plate and respond to these challenges.

The hon. Lady describes the report as “scathing”. In fact, it highlights a positive direction of travel on access to advocates and promoting good physical health, and an improved direction of travel on care after discharge, so I do not accept the tenor with which she characterised the report. I would go further and quote the deputy chief executive of the CQC, who also highlighted the parallel review by Sir Simon Wessely. He says: “We have confidence that the independent review’s solutions-focused approach to identifying priorities, based on the feedback and experiences of people across the country, will offer a review of the MHA that has the confidence of patients and professionals.” The report also highlights that Sir Simon Wessely is already undertaking and identifying actions that can be taken outside new legislation, and the CQC is very much part of delivering that.

Far from being complacent, we recognise that we have a long way to go, which is one reason the Prime Minister has put mental health firmly at the top of our health agenda. The report identifies a positive direction of travel, but we will continue to turbo-charge it and deliver sustained improvements in mental health services.

Oral Answers to Questions

Baroness Berger Excerpts

Tuesday 6th February 2018 Commons Chamber

[Mr Hunt]

I absolutely agree with that. I join my hon. Friend in supporting the introduction of waiting time targets in Scotland and other parts of the United Kingdom. How are we doing so far? In terms of the need for urgent treatment for eating disorders, we are hitting 79%, so we are on our way to the 95% target and we want to get there as soon as we can.

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

I listened very carefully to what the Secretary of State said about the additional funding that is supposed to be reaching the frontline, but the Young Person’s Advisory Service, which is the main service for young people’s mental health in Liverpool, has seen a £757,000 cut—a cut of 43%—in this financial year. There are now 412 children in Liverpool waiting more than 28 weeks for an assessment—not even for treatment. It is absolutely shocking. How can he stand there in young people and children’s mental health week and say that everything is rosy?

[Mr Hunt]

I did not; I said the opposite. I said that we need to do a lot more and I told the House what we are doing. If the hon. Lady looks at what is happening in her own clinical commissioning group, she will see that the proportion that is spent on mental health has gone up from 12.3% to 13%. She will see that this Government have done a huge amount on mental health. In 13 years, Labour did not have any waiting time targets for mental health and did not introduce parity of esteem—a whole range of things that are now happening and that she should support.

NHS Winter Crisis

Baroness Berger Excerpts

Monday 5th February 2018 Commons Chamber

[Stephen Barclay]

My right hon. Friend is absolutely right. The other issue that puts pressure on beds and hospital finances is many of the legacy private finance initiative deals. We also inherited those deals from the Opposition, which they very rarely seem to want to talk about.

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

Will the Minister tell the House why, on Friday, NHS England suspended the requirement for A&E patients to be seen within four hours until 2019, contrary to the NHS constitution, and will he amend the NHS constitution to reflect this advice?

[Stephen Barclay]

I thought the hon. Lady was going to stand up to reflect on the fact that her trust got £2.9 million of additional funding from what the Chancellor set about doing. The reality is that this Government are putting more money into the NHS and addressing the demands on the system.

NHS Winter Crisis

Baroness Berger Excerpts

Wednesday 10th January 2018 Commons Chamber

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

I refer to the comments made to the Health Committee by Jim Mackey, the head of NHS Improvement back at the start of October, three months ago:

“It is true that we are running tighter than any of us would really want to and we have not had the impact from the social care investment this year that we had hoped for; so, it will be difficult—it will be very tight—over winter.”

This Government knew what was coming, yet they have let the whole country down.

[Jonathan Ashworth]

My hon. Friend, who is an excellent member of the Health Committee, speaks with great eloquence, pointing out the hubristic response of Tory Members in saying that this was not predictable or preventable. This winter crisis was entirely predictable and entirely preventable.

NHS Winter Crisis

Baroness Berger Excerpts

Monday 8th January 2018 Commons Chamber

[Mr Dunne]

I visited the Medway hospital when it was still in special measures and saw the pressures with the configuration of the A&E and the challenges that that posed to good patient flow. I am pleased that significant investment has already gone into Medway to try to resolve some of those physical characteristics. I absolutely agree that we should praise the staff of the hospital for the work that they have done in turning it around so well.

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

Three months ago at the Health Committee, Jim Mackey, the head of NHS Improvement, told us that

“we are running tighter than any of us would really want to and we have not had the impact from the social care investment…that we had hoped for; so, it will be difficult—it will be very tight—over winter.”

The Government knew that this crisis was coming, and the social care investment to which the Minister has referred this afternoon has not been enough. Why have this Government not acted?

[Mr Dunne]

The Government have acted. We provided £2.9 million of extra money to the hon. Lady’s area to cope with winter pressures. Chris Hopson, who is the chief executive of NHS Providers, has said that this winter was better prepared for “than ever before”.

Oral Answers to Questions

Baroness Berger Excerpts

Tuesday 19th December 2017 Commons Chamber

[Mr Hunt]

My hon. Friend is absolutely right, for the simple reason that prevention is better than cure, and about half of all mental health conditions become established before the age of 14. That is why it was so significant that, following the Budget, we announced the allocation of an extra £300 million through the mental health Green Paper, precisely to improve the service we offer students in schools.

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

The Secretary of State has, on numerous occasions, to both the media and this House, referred to an increase of 4,300 staff working in mental health trusts since 2010. In response to my written parliamentary question, he was unable to clarify whether this 4,300 figure includes the 1,478 people who were rebadged as mental health trust staff following a trust merger in Manchester last year. Nor would he confirm whether this figure includes the 858 people NHS Digital says were already working in the sector, who transferred from primary care trusts to mental health trusts when primary care trusts closed back in 2013. Would the Secretary of State offer the House some festive cheer and take this opportunity to set the record straight?

[Mr Hunt]

I am very happy to offer the hon. Lady festive cheer and to explain to her that, even if her suspicion is right—and I do not believe it is—there has still been a significant increase in the number of staff employed in mental health trusts. The other suspicion she has constantly raised in the media and in this House is that mental health funding is being cut. She will know that the best news of this year is that, last year, funding actually went up by £575 million.

Mental Health Provision: Children and Young People

Baroness Berger Excerpts

Tuesday 12th December 2017 Commons Chamber

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

It may be quite late in the evening, but I wish to raise some serious issues arising from the publication last Monday of the Government’s Green Paper on children and young people’s mental health provision. I am pleased to see the Minister on the Treasury Bench and look forward to hearing her response shortly. It is a shame that the publication of the Green Paper last week was not accompanied by an oral statement when there is so much to discuss, but it is heartening to see so many Members in the House so late this evening.

After talking to people with lived experience of mental ill health, young campaigners, clinicians and parents over the past few months, I know that there was a huge degree of anticipation and expectation attached to the Green Paper. The issues are well known to hon. Members. Demand for mental health services for young people is increasing. The number of children being admitted to A&E in a mental health crisis is at a record high. Self-harm among young people, especially teenage girls under the age of 17, has increased by 68% over the past three years. Face-down restraint was used more than 2,500 times on people under the age of 18 in mental health units in 2014-15, which is the last year for which records are available. Yet face-down restraint is something that should be—and is expected to have been—phased out.

The money allocated to mental health is not reaching the frontline, and when I and many others called for the cash to be ring-fenced in the Budget, that call went unheeded. I had the opportunity to ask the Minister at the Health Committee to ring-fence the money, and her response was that:

“in my experience ring fences ultimately become ceilings.”

I tell her today that young people in my area would certainly take that ceiling.

This financial year, the Young Person’s Advisory Service, the main mental health service for children and teens in Liverpool, has been cut by £757,000—a 43% cut. We have seen a raft of cuts to other key mental health services in my area, including services for young carers and the Liverpool Bereavement Service.

A recent Care Quality Commission report confirmed that young people across the country are waiting up to 18 months to access the treatment they need. Too many are turned away because they do not meet increasingly out-of-reach thresholds. Young people are literally being turned away and told to come back when their condition is more serious.

A local primary teacher emailed me recently and set out the cases of three students under the age of 11 who had been referred by his school to child and adolescent mental health services, including one who had displayed signs of a split personality and one who had harmed the family pet without showing signs of remorse. All three referrals from that primary school were rejected. Over the past two years, 100,000 children have been rejected by services, despite being referred. I ask Members to imagine if we treated cancer the same way.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Lady on bringing such an important issue to the House at this time of the day. Taking into account reports that mental health problems affect about one in 10 children and young people and that 70% of children and young people who experience a mental health problem have not had appropriate interventions at a sufficiently early stage, does she agree that it is time not for words but for action that would see the Health Department and the Department for Education working cohesively to address the issue she has put forward?

[Luciana Berger]

The hon. Gentleman makes a really important point about co-ordination between various Departments to ultimately effect change and support young people across the country, and that is what I and so many others are really looking forward to. However, I am going to set out in the rest of my remarks why I think the opportunity has been missed.

We have seen programmes such as Channel 4’s “Kids in Crisis”, which have brought many of the issues I have set out to a broader audience. That has included the scandal of too many young people having to travel hundreds of miles from their homes to receive treatment and support—and that is if they get in at all.

We know that the younger generation, coming into adulthood, are prone to a range of mental health conditions: depression, anxiety, eating disorders, self-harm, suicidal thoughts, phobias and other challenges. Those destroy confidence, blight education, training and employment opportunities, alienate young people from society, and, in some cases, drive families to tearful despair.

There is a social justice aspect to this too. Children from the poorest fifth of households in our country are four times more likely to have a mental health difficulty than those from the wealthiest fifth. Health inequalities in our country persist as strongly in mental health as in physical health.

[Jamie Stone (Caithness, Sutherland and Easter Ross) (LD)]

Would the hon. Lady agree that, in my vast and far-flung constituency—the second biggest geographically in the UK—what she says about distance is an extraordinarily pertinent and very worrying issue for my constituents?

[Luciana Berger]

I thank the hon. Gentleman for his intervention. We have heard from many Members on both sides of the House about families having to travel hundreds of miles to access treatment. Just last week, I heard of one young person being sent to Scotland to access in-patient treatment for eating disorders, because there was not a bed available for her in England. In certain parts of the country, it is certainly the case that people have to cross boundaries and to go north and south to access services, in a way that we would not accept if this was for physical health services.

Given this growing and what I can only describe as desperate demand for services for young people, I and many others eagerly awaited the Green Paper. I have read it many times, but it was—and I hate to say this—a disappointment. I believe that Ministers have failed to meet the scale of the challenge. The £300 million outlined for mental health support in schools sounds really impressive—until we read the detail and we realise that Ministers aim to reach just a fifth of schools over the next six years, with eight out of 10 schools remaining without the extra support until 2029. It really is a drop in the ocean. Ministers intend to roll out services over the next decade as though there was no urgency or imperative for action. I hardly need to point out that this means that most eight-year-olds today will see no benefit from these proposals throughout their entire childhood and adolescence.

[Sandy Martin (Ipswich) (Lab)]

I thank my hon. Friend for bringing this important issue to the House. Does she share my concern about the waiting times between referral for treatment and the start of treatment? Does she agree that much self-harm and, indeed, suicide of young people takes place during that waiting period? Does she believe, as I do, that while four weeks would be an improvement on most of the waiting times that our children and young people have had to face up until now, that maximum wait needs to be upped to until actual treatment and not just until the assessment for treatment?

[Luciana Berger]

My hon. Friend pre-empts a question that I was going to ask of the Minister, because it is not clear whether the pilot that the Government are going to introduce is based on a four-week waiting time for assessment or a four-week waiting time for treatment. Those two things are very different. In many parts of the country, young people will sometimes have an immediate assessment but then have to wait weeks, if not months, to actually access the treatment that they need.

[Alex Chalk (Cheltenham) (Con)]

The hon. Lady speaks with passion and authority on this subject. As the Member of Parliament for Cheltenham who has witnessed this explosion in adolescent mental health problems, I share her concerns. Does she agree that as well as looking at cure, we need to look at prevention and to understand why this explosion is taking place? The time has come for a really good, authoritative body of work to get under the bonnet of why these problems are arising as they are.

[Luciana Berger]

I thank the hon. Gentleman from the bottom of my heart for that intervention, because that is the crux of the point that I am seeking to make. I have sought to highlight some of the issues in the Green Paper, and I will highlight a few more, but the greatest problem is what is not in it—namely, what we can do to prevent mental ill health in our young people rather than deal with and treat it when they become mentally unwell. I will come to that in a moment.

The Royal College of Psychiatrists eloquently states what I believe, which is that the Green Paper lacks

“a suitable scale of ambition or speed of action.”

The royal college reminds us that in the Health Education England mental health workforce plan, which sets out the posts for which the NHS aims to recruit from now until 2021, there are no new consultant psychiatrist posts for children and young people’s community services—none at all. Yet we know that there is a massive shortage of child psychiatrists in our country.

[Helen Whately (Faversham and Mid Kent) (Con)]

I commend the hon. Lady for securing this debate because it is really good to be having a conversation about this Green Paper. It is worth mentioning that it is a great moment of progress to have a joint piece of work between healthcare services and the Department for Education on getting into the issue of mental health in young people, which is such a growing problem. Like my hon. Friend the Member for Cheltenham (Alex Chalk), I think that we have to get into understanding the causes better. As the hon. Lady said, we need to take action at greater pace and to a greater scale. Does she welcome the fact that, as the Royal College of Psychiatrists says, there has been a step in the right direction in that that there is an evidence-based approach, which is to be welcomed? Does she agree that a particular challenge that must be addressed is the need to recruit and retain the workforce that we need to deliver this care and support to young people?

[Luciana Berger]

I thank the hon. Lady. I believe that we both share the concern about the challenge of recruitment within the mental health workforce. The Government themselves acknowledge that there is an issue by way of the fact that they have put forward a plan to recruit these extra thousands of mental health workers between now and 2021. In the context of our conversation this evening about young people in particular, it is particularly disheartening and dispiriting that the specific plan that was set out only a few months ago contains nothing to expand the number of child psychiatrists—something that we desperately need. In the north-west, we really struggle to fill vacancies for those posts.

[Rachael Maskell (York Central) (Lab/Co-op)]

My hon. Friend is making a great speech about the real crisis in child mental health. Does she agree that the Green Paper places more and more focus on teachers, as opposed to health professionals, providing mental health support? Teachers are already really stressed by the volume of work that they have to do and they are not trained as medical professionals, so should that emphasis change?

[Luciana Berger]

I thank my hon. Friend for that important contribution. Another question that I hope the Minister will answer is how we can properly equip and train teachers to contend with the responsibility that they will be given if the plan set out in the Green Paper goes ahead. At the same time, the Department for Education is piling extra pressure on students with more testing. There are fewer teaching staff, which adds to the pressure on the remaining staff, and class sizes are larger. Cuts have been made to mentors, pastoral care and counselling. There has been a 13% reduction in the number of educational psychologists in our schools. The Royal College of Nursing points out that the number of school nurses has dropped by 16%, while the number of school-age pupils has gone up by 450,000. Young people face bullying, online threats, dysmorphic body image and advertising in a way that no previous generation has done.

Like many hon. Members, I am upset, appalled and outraged every week by the heartbreaking cases that constituents and their families raise with me in person or via email. Many Members in this House will recall the case in August of 17-year-old Girl X. She was restrained more than 100 times in a place that was not fit for her care, and she was left without a secure bed. The UK’s most senior family court judge, Sir James Munby, raised her case and warned us that we would have “blood on our hands” if this suicidal and vulnerable young woman did not get the treatment that she needed. But why was his continued intervention needed?

The case of Jack was brought to me this weekend. Jack is eight years old, and he has autistic spectrum disorder. He is in a severe state of anxiety and distress, and he has spent the last eight weeks on a ward in Alder Hey Children’s Hospital. He has had no specialist support from CAMHS and no specialist in-patient bed. He is getting more ill, and his family are, in the words of his mum Kerry, “in complete crisis.”

Just this afternoon, I heard about the case of Martha, who is 15 and has a history of self-harm. She has been admitted to A&E twice after taking an overdose. From a referral in June, Martha is still waiting to see a mental health professional. In the cases that I have described and thousands like them, every day counts, but young people are waiting weeks and months for treatment while their conditions worsen and their families are left distraught.

I do not believe that the Green Paper does anything for young people such as Jack, Martha or Girl X, or for thousands of other young people, whose lives should be filled with optimism and wonder as they look to a future laden with promise. I am concerned that instead, they are going to face years of torment, anguish and pain, made worse by the fact that so much of it is preventable. The majority of adults with diagnosable mental health conditions will have developed them under the age of 18. The life chances of thousands are being blighted. We are leaving a generation in pain; they are being let down because the care is not there.

Ultimately—I agree with the point made by the hon. Member for Cheltenham (Alex Chalk) —what is missing is the proper focus on prevention. How can we prevent mental ill health and keep our children well? We know that the first 1,001 days of a child’s life determine their life chances and life outcome, and that is why the previous Labour Government invested millions in Sure Start and children’s centres. We need to remove the factors that create mental ill health in the first place: neglect, childhood trauma, domestic abuse, bullying, insecure housing and poverty. Unfortunately, the Green Paper does not address those issues. Indeed, the words Sure Start, deprivation, homelessness and inequality do not appear in the Green Paper even once.

We do not need to be economists to understand that it is far more expensive to run a service that is based on crisis than a service that is based on prevention, not just in human terms, but in terms of taxpayers’ cash. What a wasted opportunity. I sincerely hope that the consultation on the Green Paper will be meaningful, that Ministers will listen to the voices of young people and experts across the country who are crying out for change, and that we will see some action.

In conclusion, will the Minister tell the House—I have asked this question, but let me reiterate it—whether the pilot, which I know is only a pilot, will introduce a four-week waiting target for assessment or for treatment? The Green Paper guarantees funding only for the period of the spending review, so what guarantees can the Minister offer us for maintaining funding after the initial three years are up? What will happen then? How will the lucky fifth of schools be selected for the first wave of support? How will her Government address the aim of real parity of esteem between mental and physical health? Reading the Green Paper, it seems to enshrine imparity by supporting only 20% of children over the next six years. Finally, is she convinced that this really is the best her Government can do for the greatest asset that we possess—our young people, who are our nation’s future?

--- Later in debate ---

[Jackie Doyle-Price]

I thank the hon. Gentleman for his intervention. I am pleased to acknowledge that I have a very good dialogue with the Scottish Health Minister. It is fair to say that all four nations can learn from each other when it comes to delivering better health outcomes and sharing best practice.

We know that young people are sometimes still taken to police cells when they are in a mental health crisis. The hon. Member for Liverpool, Wavertree outlined the very distressing case of the young woman who had been restrained many times. The Under-Secretary of State for the Home Department, my hon. Friend the Member for Louth and Horncastle (Victoria Atkins), and I yesterday announced new police provisions that will finally put an end to this practice. We will ensure that children will always be taken to places of safety. The issue of prone restraint for children really needs to be examined.

The Green Paper will build on these foundations to build a new approach to supporting the mental health of our children and young people. With over £300 million of funding available, we will train a senior designated mental health lead in every school and college to improve prevention work—many schools have already made that commitment—and create brand new mental health support teams working directly with schools and colleges, and we anticipate that they might be working within multi-academy trusts or through local education authorities, and some might be provided through the NHS. Through the pilots we will discover what works, and it will not necessarily be a one-size-fits-all approach.

[Luciana Berger]

I am conscious of the time and that the Minister will soon conclude her remarks, but I have two points that I would like her to respond to. Does she accept that what she is laying out is essentially replacing much of what has been lost in schools: the number of educational psychologists, peer mentors and counsellors lost from our schools because they do not have the funds to pay for them? I hope in her final remarks she can address prevention, which is a very serious point. What are she and the Government going to do to prevent mental ill health in our young people?

[Jackie Doyle-Price]

I do not accept the premise of the hon. Lady’s first point. We are trying to build a critical mass that schools will have access to. On prevention, the investment we are making in mental health first aid and training in schools will enable staff in schools to see when people are going through mental ill health issues. The earlier we can put that support in place the better. We are working with the Department for Digital, Culture, Media and Sport on what we can do through social media. We know that online bullying is causing a lot of mental health issues. As I say, this is a Green Paper. We are making money available. We want to see what works and we want to take this forward in a consultative manner. We will respond fully to any points made as a result of that consultation.

Autism Community: Mental Health and Suicide

Baroness Berger Excerpts

Thursday 30th November 2017 Commons Chamber

[Dr Cameron]

I wholeheartedly agree. As I said, the police are on the frontline. They face the crux of the matter when it comes to matters of life or death. They are doing their very best with the training and resources that they have, but there requires to be a clearer pathway so that people who are at that crisis stage can access health services—and probably crisis health services—and so that the police have somewhere to ensure that the clinical needs of those people are met. It is unfair for our police to have to take care of people’s clinical needs when that is not what their training provides for.

In 2016, an academic study in Sweden, which was published in the British Journal of Psychiatry, found that people with autistic spectrum disorder were nine times more likely to die by suicide than the rest of the population. The latest research indicates that people with autistic spectrum disorder account for a harrowing proportion of suicides in the UK. There is a 16-year gap in life expectancy between people with autistic spectrum disorder and the general population. To put it all very bluntly, people with autistic spectrum disorder are 28 times more likely to consider suicide than the average population —28 times. The statistics make one thing abundantly clear: what we are doing now to support people with autistic spectrum disorder is not working and is not enough. Research shows that almost seven in 10 people with autistic spectrum disorder experience mental health issues, including anxiety and depression. Services must be in place to ensure that people are cared for holistically. We have to meet all their clinical needs, which may mean their autism or their learning difficulties, but they will almost certainly have mental health issues. Quite frankly, we do not have services in place today that take account of the complexity of such needs.

What types of things are going wrong for people at the frontline? It is difficult for people with autistic spectrum disorder to access mental health support through the usual routes. For most of us, that might mean going to our GP as a first point of contact for primary care for mental health problems, but a GP practice is a daunting, unfamiliar place for people with autistic spectrum disorder. One young man wrote to me and described a recent trip, saying that it was

“quite hard for me to access the GP anyway. The whole environment is difficult. It’s noisy, there’s often children, it’s very hot. There’s also a loud beep when they call the next person that I find really quite painful. When you’re feeling emotionally poorly that becomes almost impossible.”

GP surgeries make reasonable adjustments for wheelchair users every day—simple changes that make the life of the patient easier—so the same policies should be implemented for people with autistic spectrum disorder. We need training to raise GP awareness. Access needs to be easier. We need to ensure that GPs know who on their register has a diagnosis of autistic spectrum disorder.

If an autistic person bypasses the GP and goes straight to mental health services, they may face unprecedented waiting times or they may simply be refused treatment. When individuals do attend services, they may find that they are discharged without any follow-up. At the Health Committee last week, we heard how a young autistic boy was turned away by child and adolescent mental health services four times, despite feeling suicidal, because he had not yet attempted to take his own life. Things have hit crisis point, and we need to ensure that we engage in prevention. Someone attempting to take their own life should not be the point at which they receive treatment. We need early intervention to pinpoint the symptoms of difficulty and where we should be aiming the treatment.

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

I thank the hon. Lady for securing this very important debate. We both sit on the Health Committee, and during the inquiry into suicide prevention we heard that the point at which someone is most likely to take their own life is, tragically, when they are discharged from in-patient care. The Committee’s recommendation was that everyone should be contacted within at least three days, and we are waiting for the Government to respond that. Does she agree that everything should be done to ensure that the most vulnerable, including people with autistic spectrum disorder, should be supported in that period when they are extremely vulnerable to ensure that they do not take their own life?

[Dr Cameron]

I agree. That is an extremely valid point. If people arrive at A&E for crisis intervention and are admitted for a period of time, it is important that they are discharged with some follow-up. People often return to the same circumstances that led to the difficulties in the first place, and if they do not have some support to deal with those difficult circumstances, they may be in a vulnerable situation and may try to self-harm or take their own life once again.

If a person with autistic spectrum disorder feels unable to go to the GP or to reach out to services in their local community, they might try to ring a suicide helpline. However, that can be extremely difficult in itself for a person with autistic spectrum disorder who finds communication and social interaction difficult. They might be able to verbalise only some of their difficulties, and they may then find there is no follow up from that service, either. Early access points and early intervention are crucial to preventing suicide and preventing mental health problems being exacerbated. Much more has to be done at that critical early intervention stage to ensure access to services.

If a person with autistic spectrum disorder reaches a health professional, they often find that their mental health problems are overlooked or misdiagnosed, which might be because they present an extremely complex case. They might also have concomitant learning difficulties, and they might not present the symptomatology that would usually be expected for anxiety or depression per se because their symptoms are complicated by their autistic spectrum disorder. It is extremely important that mental health practitioners have training in autistic spectrum disorder, in the types of presentation that they might need to identify and, particularly, in risk issues.

Diagnosis is still a postcode lottery. I hope to continue working with the Minister on that issue, because we need an understanding of who is appropriately trained in diagnosis of autistic spectrum disorder and what level of specialty we have in different professions. What is the workforce plan to ensure that this very great need is addressed across our society? This is so important. People with autistic spectrum disorder say they do not know where to go locally. As a member of the Select Committee on Health, I have asked services about that, and they say, “We don’t really have a map of who can diagnose and who can provide specialist intervention in a given area of NHS England.” Streamlined services would make it so much easier for people to gain that initial access.

I do not want to take up the whole debate, so I will provide a brief overview before letting others speak. Many Members want to contribute to this important debate, but I wish to touch on a few other important issues.

I request that the Minister look at what mental health therapies work specifically for people with autistic spectrum disorder who have concomitant mental health difficulties. There is no adequate research base yet, but we know it is critical—it is lifesaving—so we need to prioritise funding. Traditional mental health therapies might not work in the same way for people with autistic spectrum disorder. If one of us presented at a GP surgery, we might be offered cognitive behavioural therapy, but we do not know whether that is the best option for a person with autistic spectrum disorder, or whether some kind of adapted therapy would be more appropriate. That important work should be undertaken, and undertaken quickly, to engage people in appropriate therapies and save lives.

I have been contacted by a couple of individuals whose poignant accounts have struck me. One is an individual from my constituency who says that she has continually tried to access CAMHS for her daughter, who has been repeatedly self-harming. It has placed the family in such a stressful situation over a lengthy period that the family, including the mother and carers, now feel that their own mental health is under stress.

It is extremely important that we ensure not just that individuals can access the system but that we preserve family life, that we support carers and families, and that we do not place an additional burden on the NHS and other services. Families and parents may go on to develop their own depression and anxiety when dealing with an intractable situation because they do not know how to cope. If we do not address the problem at its root, we will multiply the problem for services across the UK.

--- Later in debate ---

[Mrs Anne-Marie Trevelyan (Berwick-upon-Tweed) (Con)]

It is a pleasure and honour to speak in this debate, secured by the hon. Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron), because it is such an important issue. It is critical to make sure that those on the autistic spectrum are absolutely wrapped up in our mental health and medical services so that we no longer need even to raise this issue in the House. To that effect, the Government have put mental health on the political agenda as no Government have before. We have invested more in mental health than any previous Government, hired tens of thousands of staff and, most importantly, enshrined the parity of esteem of mental and physical health into law. The Prime Minister took a big step forward last month by opening a review of the Mental Health Act 1983, because too many people are still suffering discrimination.

[Luciana Berger]

I do not seek to be partisan in these sorts of debates, but it is important to note for the record that the amendment to introduce parity of esteem for mental health into the Health and Social Care Act 2012 was tabled by Labour peers in the House of Lords, and unfortunately Tory peers voted against it. I would not like the Government to seek to claim credit for the fact that parity of esteem is now enshrined in law.

[Mrs Trevelyan]

I thank the hon. Lady for her comments.

Despite the cross-party efforts of all those for whom this is a passionate policy area—for 18 years I have cared for my son, who is now a young adult with autism—there are some people who are having a miserable time in the mental health system and are not yet benefiting from improved access to core therapies and services: men and women throughout the country on the autistic spectrum. We must do better.

Across the board, a quarter of us will experience mental ill health during our lives, but within the autism community that rises to eight in 10—of those diagnosed as autistic, eight in 10 suffer from mental ill health. To those of us familiar with autism, that is sadly not a surprise. Society is designed for us neuro-typicals, as my son likes to call me—I am not sure it is meant as a compliment—so almost everything designed for us can cause stress or worry for those who are wired differently. A different perspective on the world has huge potential benefits for our society and economy, and we fail all those on the autistic spectrum to the detriment of not only the individual but society more widely.

We are failing these individuals. When I did some research for this debate—as I always do, if I can, for anything relating to this subject—I was appalled to discover the scale of suicide across the autism community. Autistica, the UK’s autism research charity, revealed international findings that autistic people without a learning disability are nine times more likely to die by suicide than the rest of the population. The charity’s research is now beginning to uncover almost identical rates in the UK as it starts to build the research database. As a parent, that is just awful to hear; but as an MP, it is a rallying cry. The exact causes are still being researched. We live in a complex environment and people are complex anyway. If we stick them in an environment that is often alien, it is not surprising that it is sometimes too hard to cope.

There are three clear ways in which our mental health services are letting our autistic citizens down now, and we have a duty to address them. First, we know that autistic people’s mental health problems are often misdiagnosed or missed completely. Despite mental health problems being the norm, there are no systematic mental health checks for autistic people. These problems can often present very differently, partly because so many become practised at masking their feelings to fit in. If someone is severely autistic, it is perhaps almost easier to identify them as sufferers, but those who are managing to live in a mainstream environment have learned some extraordinarily clever, adaptable ways to cope with our neuro-typical world and to their own very severe mental ill health. What is truly traumatic for one autistic person might not be for another, so when they do seek help, as the hon. Member for East Kilbride, Strathaven and Lesmahagow highlighted, autistic people can often find that their worries are dismissed out of hand. They are missed or misunderstood.

The NHS Five Year Forward View for mental health recommends the development of autistic-specific care pathways for mental ill health. That work, as I understand it, is supposed to begin in 2018, but we have heard nothing about it since February. Perhaps the Minister will be kind enough to update us on the project: is it still taking place; who is leading it; what is its scope; and how will autistic people be involved in helping to design it to make sure that we are not missing some very obvious things? Those things might not necessarily be obvious to those of us who are neuro-typical, but we must think in the different way that our wonderful autistic community so often does. This is a crucial opportunity to begin transforming care for autistic people, but we must get it right.

Secondly, we know that autistic people can struggle to find the support that works for them. It is assumed that what works for us neuro-typicals will also work for them. Autistic people may benefit from cognitive behavioural therapy but, as the hon. Lady who is an expert in providing such support says, being made to group work with strangers can be entirely counter-productive. We need to think about how we can adjust that support. The idea that someone who has issues with understanding, with being able to read faces, with processing information would in any way feel supported when they are in a state of deep stress shows a complete gap in understanding. The stresses and the symptomatic problems of people with autism make it more difficult for them to cope.

Oral Answers to Questions

Baroness Berger Excerpts

Tuesday 14th November 2017 Commons Chamber

[Mr Hunt]

My hon. Friend is right to challenge me on that, because we are asking all clinical commissioning groups to increase their funding for mental health in real terms year in, year out. Some 85% of CCGs are doing that, and an extra half a billion pounds reached the frontline of mental health last year. Regrettably, Croydon is not part of that 85%, so I will take his question away and find out exactly what is happening.

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

How does the Secretary of State expect to achieve the plans to increase the mental health workforce when only last week the head of NHS England, Simon Stevens, said:

“On the current funding outlook, it is going to be increasingly hard to expand mental health services”?

[Mr Hunt]

It has been challenging to expand mental health services over the past seven years due to the financial pressure on the NHS, but we have succeeded. We have 4,300 more people working in mental health trusts and £1.4 billion more is being spent on mental health than three years ago. We have a plan—it is a good one—and we are going to ensure that it happens.