The National Health Service

Debate between Baroness Berger and Norman Lamb

Wednesday 23rd October 2019 Commons Chamber

[Luciana Berger (Liverpool, Wavertree) (LD)]

It is a pleasure to follow the hon. Member for Hartlepool (Mike Hill) and I share a number of the assessments that he made in his contribution, because as the House pursues our debate on the Queen’s Speech, it is becoming ever more apparent that the casualty of a Tory Brexit will be Britain’s national health service.

The NHS is our greatest national asset; it is the product of the fusion of radical and enlightened minds in the last century that gave us healthcare for all based on need, not means. But now, in this century, the NHS is in great peril from a toxic combination of chronic underfunding and withdrawal from the EU, and responding to very different challenges from those when it was first created so long ago.

Notwithstanding the announcements in the Queen’s Speech, let us be very clear that the NHS is not in receipt of the resources that it needs to be effective. That was discussed only yesterday at the Health and Social Care Committee, when we had with us the Secretary of State and we talked about the backlog of £6 billion in NHS repairs alone, so an announcement of half that really is no cause for celebration. We heard from the Health Foundation, and its assessment of the Queen’s Speech funding announcement says that

“it falls well short of the scale of the challenge.”

We have a Prime Minister who announced 40 new hospitals, which then was downgraded to six within days, and we see demand for healthcare from our growing and ageing population outstripping the availability and quality of services, which means rationing and a diminution of quality of care; many right hon. and hon. Members from both sides of the House have referred to that in the debate this afternoon.

[Norman Lamb]

Does my hon. Friend agree that another sign of a system under unacceptable strain is the fact that teenagers around the country are often waiting a year or more for access to mental health treatment? I know of two teenagers who have recently had their first appointment after a year of waiting, which seems to me to be utterly intolerable.

[Luciana Berger]

I thank my right hon. Friend for making that really important contribution, and waiting times are a particular issue in our NHS, especially in the Cinderella of all Cinderella services, our CAMHS. Too many young people right across our country are struggling to get a referral and then, if they do get that referral, having to wait months on end. Frankly, it is unacceptable.

Mental Health First Aid in the Workplace

Debate between Baroness Berger and Norman Lamb

Thursday 17th January 2019 Commons Chamber

[Norman Lamb]

I absolutely do. I was going to say, “Don’t talk to me about the work capability assessment, because it will get me very angry.” We need reform of the welfare system to help to facilitate people returning to work, rather than just treating them as second-class citizens, as it often does.

[Luciana Berger]

I am listening very carefully to the right hon. Gentleman’s remarks, which are very pertinent. On people being in work or not in work if they are affected by a mental health condition, I was struck to learn that for my local mental health trust, Mersey Care, which provides services for the whole of Merseyside, the latest available figures—not the most recent financial year, but the previous one—show that just 3% of the patients under its care, in both the community and in in-patient services, were in any form of work. That figure is similar for patients under the care of many mental health trusts across our country. Does he believe that people outside this place might not be aware of that fact, but it is staggering and should concern us all? We should be doing everything possible to support people with mental ill health conditions into the workplace.

[Norman Lamb]

I totally agree. My plea to the Government is that, as we hopefully commit to spending more on mental health, we spend at least part of that on preventive measures. If we can get someone into work, it makes a whole difference to their lives. The evidence shows that many people who are helped back into work are then able to stay in work; reducing the burden on the NHS and the benefits system, but giving people dignity and self-respect.

Another initiative we are undertaking in the west midlands is the wellbeing premium. It was my idea, which again is being supported by the Government and I am grateful to them. The idea, which we are trialling over a year, is to give an incentive to employers to improve the way in which they support people in work by training their line managers—the most critical thing one can do—and see whether we can reduce the number of people who end up on sickness absence. The idea is to give them a temporary incentive for one or two years, for example by a reduction in the business rate or a reduction in national insurance payments. If by that we can reduce sickness absence, the number of people falling out of work through ill health and the problem of presenteeism, everyone benefits. It will be interesting to see how that succeeds.

In the west midlands, we are also pursuing the thrive at work commitment, which is trying to build a social movement of companies that all sign up to a commitment to up the level of support that they provide people, changing the culture in workplaces. A toolkit is provided to companies, and that could make a substantial difference across the region.

The action plan also has a commitment to train up 500,000 people across the west midlands in mental health first aid. That is a totally different approach to what we have been used to, which is an NHS very much focused on sickness and providing treatment for sickness after what is often a very long wait, as the hon. Member for Plymouth, Moor View pointed out. Instead, the whole focus of the system should be on prevention. If we do that, we can achieve a real breakthrough.

To conclude, let us amend the legislation and get mental health first aid to become the standard in every workplace. Critically, that should be part of a much wider programme that is focused on prevention and on building good healthy workplaces with the right culture, where people have respect, are engaged in the work they are doing and are treated with dignity. With that commitment is a dedication to the work they are doing and a commitment to raise awareness of mental ill health among all staff and to train managers properly. Through a combination of regulation and incentives, we can make a real difference for people.

Transforming Care Programme

Debate between Baroness Berger and Norman Lamb

Thursday 5th July 2018 Commons Chamber

[Norman Lamb (North Norfolk) (LD)]

I beg to move,

That this House is concerned at the slow progress made under the Transforming Care programme, which was set up to improve the care and quality of life of children and adults with a learning disability and/or autism who display behaviour that challenges; recognises that a substantial number of people with learning disabilities remain trapped in, and continue to be inappropriately admitted to, Assessment and Treatment Units rather than living with support in the community; is further concerned at the lack of capacity within community services; notes evidence of the neglect, abuse, poor care, and premature deaths of people with learning disabilities; believes that the Transforming Care programme is unlikely to realise the ambitions set out in the Building the Right Support strategy before it ends in March 2019; calls on the Government to establish, prioritise, and adequately resource a successor programme that delivers a shift away from institutional care by investing in community services across education, health and social care; and further calls on the Government to ensure that such a programme is based on lifelong support that protects people’s human rights and promotes their independence and wellbeing.

May I thank the Backbench Business Committee for facilitating this important debate? Although the number of Members who have indicated a desire to speak is low, this incredibly important issue deserves to be debated in the House. I thank the hon. Member for Dulwich and West Norwood (Helen Hayes), together with other Members, for joining me in making the application for the debate. I have worked very closely with her on this issue, which we both care very much about.

I thank a number of voluntary sector organisations that have been incredibly helpful in preparing for this debate. I particularly want to mention the Challenging Behaviour Foundation, which is led by the very impressive Viv Cooper, as well as Mencap, the National Autistic Society, the Voluntary Organisations Disability Group and Shared Lives Plus.

It is perhaps sobering that we are debating this issue on the 70th anniversary of the NHS. I say that as someone who is a very strong supporter of the NHS, but for the people we are talking about in this debate, the record has not been a good one. The system has let down too many individuals and too many families. On this very significant day, it is important to recognise that the NHS has a lot of work to do to repair the damage that has been done to so many people, and to treat them properly.

The origins of the transforming care programme lie in the horror of the Winterbourne View scandal, which Members will remember. In that private hospital, people with learning disabilities and autism were abused and assaulted behind locked doors over a sustained period, and that was only revealed by brave whistleblowers. In the aftermath of that horror, I invited the families of those who had been patients in Winterbourne View to come to the Department of Health—I became a Health Minister in September 2012—to talk to me about their concerns.

I clearly remember a father called Steve Sollars, who talked to me about how he had watched his son become, in his words, increasingly zombie-like as he was pumped full of anti-psychotic drugs. Steve described how he tried to complain to the local authority and the primary care trust, as it was in those days, and said that he was just completely ignored. It really struck home when he said, “I felt guilty that I couldn’t do anything for my son.” I was left thinking how dreadful it was that we had got to a position in which state agencies had left an individual—a father—feeling guilty because they were ignoring his pleas for something to be done.

In the following months and years, I met some other parents of individuals trapped in hospital—sometimes in unattractive institutions—for long periods, all of whom felt that no one was listening to them. I refer in particular to Phill Wills, who campaigned brilliantly on behalf of his son Josh, who was stuck in a hospital in Birmingham for more than two years. The family live in Cornwall, so they had to make an incredible journey just to maintain contact with their little son.

I also met Shahana Hussein, the aunt of a girl called Fauzia, who was in St Andrew’s in Northampton. She talked to me about her fears of how her niece appeared to be trapped there. She was anxious that that might be her life course, and that she would never emerge from that place. I met Lynne McCarrick, whose son Chris had been stuck in Calderstones undergoing inappropriate treatment for a very long time, and Lorna and Sid, the parents of Simone, who is still stuck in hospital nine years after her first admission. For much of that time, she has been a long distance away from home, therefore making it impossible for her parents to visit, which is shocking in this day and age. Many of those families are present for today’s debate, and they remain extremely concerned about their loved ones and others who remain trapped in institutions.

The conclusion that I reached at that time, which I still hold, is that individuals’ human rights are routinely ignored and breached in serious ways. Someone who is convicted of a criminal offence and then sent to prison—other than the cohort who have received indeterminate sentences—generally knows the date of their release. However, people who go into institutions and their families do not know a release date, and many people stay in those institutions for much of their lives, which is shocking. To put it bluntly, they are treated as second-class citizens. I said that at the time, and I still say it now, because not enough has changed for any of us to be comfortable with the situation.

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

I congratulate the right hon. Gentleman and my hon. Friend the Member for Dulwich and West Norwood (Helen Hayes) on the leadership they have shown by securing this debate through the Backbench Business Committee. The right hon. Gentleman said that this programme came out of the Winterbourne View scandal, which was back in 2011. Does he share my concern that we are discussing this issue seven years later in 2018 and yet thousands of people in our country—thousands!—are still in institutional care? It is an absolute disgrace that we find ourselves discussing this issue.

[Norman Lamb]

I completely agree. That sense of complete injustice and the denial of human rights still exists. Nothing much has changed, which is why the debate is so important, and I share the hon. Lady’s view that we should not tolerate this scandal. What makes the situation even worse is that this is not a demand for vast amounts of extra public money; it is about how public money is spent. Our demand is that money is spent in a way that respects people’s human rights and gives them the chance of a good, happy life in the community, with the support of care workers, friends and family, rather than being trapped in institutions. It is shocking that the situation for very many people has remained exactly the same as it was all those years ago.

[Norman Lamb]

I do agree, and that is another big subject that I will be pursuing further in the light of the Gosport inquiry, which I established when I was a Minister. In that case, brave nurses tried to blow the whistle in 1991, but they were shut down by management and unable to pursue their concerns. More than 456 people lost their lives as a result of the inappropriate prescribing of opioids, and that was because whistleblowers—brave staff members—were not listened to. In every part of our health service, we must ensure that people feel able to speak up and that they have the legal rights to do so.

The outcome of our deliberations in the Department was to establish the transforming care programme, which was published in December 2012. Interestingly, it was pursued as a concordat and an agreed programme of action. It was supported by an amazing array of organisations, all of whose logos appeared in the document, including—critically—NHS England. Every organisation that signed up to the programme committed to

“working together, with individuals and their families—

note the phrase “with individuals and their families”—

and with the groups that represent them, to deliver real change.”

That was in December 2012.

These organisations that had committed “to deliver real change” also stated:

“Our shared objective is to see the health and care system get to grips with past failings by listening to this very vulnerable group of people and their families, meeting their needs and working together to commission the range of support which will enable them to lead fulfilling and safe lives in their communities.”

To put it bluntly, there has been a shameful failure on that commitment to change, which simply has not happened for the majority of people involved.

At that time we were operating in a fog. No data had been collected historically on the numbers of people in beds in institutions, so we had to rely on periodic censuses to find out whether anything was changing. When we conducted a census about 18 months after the start of the programme, it was shocking to discover that there had effectively been no change—it was business as usual. The really disturbing thing was that many private sector organisations were making substantial investments in new facilities and delivering the wrong model of care. Why did those organisations have the confidence to make major million-pound investments in inappropriate care? It seems to me that to justify such investment, they must have had reassurance from somewhere in the system that things would carry on as they were. It was shocking to discover the extent to which it was simply business as usual.

[Luciana Berger]

I apologise if the right hon. Gentleman is going to come on to this, but I want to reflect on the reports commissioned by NHS England and Sir Stephen Bubb. Back in 2014, Sir Stephen was commissioned to write a report entitled “Winterbourne View – Time for Change”, yet nothing happened in the wake of that report, other than a closure programme that was published back in 2015, on which we have seen little progress. In February 2016, Sir Stephen Bubb published another report entitled “Time for Change – The Challenge Ahead”, which again demanded urgent action. Does the right hon. Gentleman share my concern that although those reports were commissioned, there was very little response or action taken?

[Norman Lamb]

Again, I entirely share the hon. Lady’s view. I work closely with Sir Stephen Bubb and we have exactly the same view about this. He and I attended a meeting about a year ago with NHS England to discuss progress, or the lack of it. The hon. Lady is right to say that there is a culture of looking at things again and again, and then doing nothing about the conclusions reached, which is wholly unacceptable.

At that time, three issues stood out, and they involved perverse incentives that acted to prevent change from happening. First—this is extraordinary—the person who was making the critical decision about whether an individual should stay in a bed or be discharged was, and still is, the clinician employed by the provider organisation that makes money out of the person staying in the bed. That total conflict of interest has never been confronted. As Minister, I kept asking NHS England to act to address that issue, but it has not yet been resolved. If a private sector organisation is earning £4,000 or £5,000 every week from someone being in a bed, there is a strong incentive to keep them in that bed. There is also an incentive for public sector organisations that want to maintain their existence, and that conflict of interest has never been confronted.

Secondly, there is a complete failure to invest properly in community provision. This is all about the need to shift resources from institutional care to community support; in other words, shifting money from NHS England to local authorities. The original transforming care concordat made it clear that there should be a pooling of resources between specialist commissioning, clinical commissioning groups and local authorities. As the hon. Member for Liverpool, Wavertree said, seven years on we are still waiting for a proper pooling of resources so that the money can actually shift and investment can be made in community resources.

The third insight I had at that time was the most extraordinary and wholly unacceptable exclusion of families and individuals from any decisions that were being made about their care. This, I am afraid, continues today. It is very far from the personalised care that the NHS and the Government say they are committed to. In the light of what I saw as our complete collective failure to deliver that change—this was the thing that caused me most distress as Minister—I decided that we had to come up with new proposals for new legal rights, so that families and individuals could challenge decisions that were being made behind their backs about where they would be cared for and treated.

Shortly before the 2015 general election, we published a Green Paper, I think in March 2015, called, “No Voice Unheard, No Right Ignored”. It has an important title, but I am afraid that those rights and those voices are still unheard and ignored because it has never been implemented. Nothing proposed in the Green Paper has been taken forward by the Government. We now have a review of the Mental Health Act 1983, so there is another opportunity to address the scandalous lack of rights for individuals, but the time it will take before there is any legislation will be very long—I doubt whether it will be in this Parliament—and families will just be left waiting.

At that time I worked with Sara Ryan, a remarkable woman and the mother of Connor Sparrowhawk, known as Laughing Boy. He was a young man in the “care” of Southern Health who lost his life while he was within its institution. He drowned in a bath because of neglect. The Health and Safety Executive had decided not to investigate the case. I intervened and asked it to reconsider. It then decided that it could investigate and eventually, years later, prosecutions and convictions followed. The result of the tragedy that struck that family was that Sara Ryan and an amazing group of people worked together to produce a Bill that would have strengthened the rights of individuals. We worked closely with them in the production of that Green Paper.

Because no progress was being made following the 2015 general election, the Government and NHS England embarked on a new process. In October 2015, they published a document called “Building the Right Support”. The plan was to close between 35% and 50% of in-patient beds and, critically, ensure that local areas developed the right community support by—this is the critical date—March next year. The plan involved the creation of 48 transforming care partnerships covering the whole country. These partnerships between NHS England specialist regional commissioners, local authorities and CCGs were to facilitate the shift of money from NHS England to local authorities, so that people could be cared for in the community.

There was a plan for people who had already been in in-patient care for more than five years at April 2016 to be given a dowry to facilitate their transfer into community support. When campaigners asked how many dowries had been provided, NHS England said it did not know because it did not have any records on that. What kind of implementation of a national programme is it when we do not even know, and have no way of telling, how many dowries have been delivered? And why was it just for that one cohort of people? Surely every person stuck in a hospital or institution has the right to have the money go with them on their journey back into the community. I want to know from the Government how many dowries have been delivered so far and whether they will become part of the programme in the future.

As I said, the programme ends in March next year, along with other work on learning disabilities which campaigners are concerned will continue—I will come back to that at the end—including the learning disabilities mortality review. There has already been a lot of concern expressed about how the annual report was slipped out the day after the local election at the beginning of May. The report contained pretty shocking findings, with life expectancy falling massively short of the rest of us—for men by about 22 years; for women, by 29 years—without any clear justification. Some 13% of the cohort of people looked at in the mortality review were cases where the person’s health had been adversely affected by delays in care or treatment, gaps in services or organisational dysfunction, neglect or abuse. Those findings are shocking and concerning. The question for the Government, which I will come back to, is what happens with the findings of mortality reviews. We can all express concern when they are published, but unless there is a plan of action to address the failings identified in them then nothing will change.

The nine principles in the “Building the Right Support” document are very good. They are all focused on personalised care and getting people into the community, which we all agree must happen.

[Luciana Berger]

I normally would not make so many interventions and I hope the right hon. Gentleman is happy to take them—I thank him greatly. I just want to reflect a bit more on the learning disabilities mortality review. The title is quite technical, but it comes back to what he opened his speech with: we are discussing thousands of the most vulnerable people in our country and we have a responsibility to do everything we can to compensate for the fact that they are so vulnerable. The mortality review, launched in May of the previous year, found that one in eight of the deaths reviewed showed there had been abuse, neglect, delays in treatment or gaps in care. Today we celebrate the 70th anniversary of the NHS. Is it not a sad reflection that, amidst all the positivity, we need to do something about this issue so urgently?

[Norman Lamb]

I totally agree. It is, as I said at the start, sobering. In a way, all of us who strongly support the NHS must not laud it as a perfect institution with nothing to complain about. As far as this group of people are concerned, they have been very badly let down. Fundamentally, in many cases they have died early through neglect. That is intolerable in this day and age.

The nine principles, which are positive and empowering, are really good. I sign up to them completely. It is the implementation that is lacking and has largely failed. I say to the Minister that she is very fortunate to be in her wonderful job. My great frustration is that this programme came early in my time as Minister, but I learned, as I did the job, just how critically important implementation is. You think that by establishing good principles and getting everyone to agree to implement them those organisations will do what they have committed to do. It was probably naïve to think that. The reality was that nothing changed and it still has not changed. One critically important lesson to learn from that failure is to have a total, obsessive focus on implementation and national leadership.

Health and Social Care Committee and Education Committee

Debate between Baroness Berger and Norman Lamb

Thursday 10th May 2018 Commons Chamber

[Luciana Berger]

That is a critical issue that was raised on a number of occasions. A cliff edge exists between the services that young people receive until 18 and what happens when they then try to access adult services. The services are very different. In one part of the country, where services go up to 25, this is working very successfully. That was a recommendation in “Future in mind”, a report published back in 2014. We were firmly of the opinion that the Government should actively address this situation and see it amended across the country.

[Norman Lamb (North Norfolk) (LD)]

I congratulate the hon. Lady on her statement and the Committees on this excellent report, which I endorse. Does she agree—she touched on this issue—that the absence of a real focus on early years before children get to school, and the absence of any real, in-depth understanding of the impact of adverse experiences of trauma, abuse or neglect in early years, is a gaping hole? Does she agree that the Government need to go back to the drawing board to extend the scope of the Green Paper to really focus on this issue, to gain a better understanding of it?

[Luciana Berger]

I thank the right hon. Gentleman for his important contribution. One of our key recommendations was that the Government should publish the evidence review alongside the response to the report. They limited the scope of the Green Paper too early by restricting the terms of that evidence review. In fact, we heard in evidence that evolved during our inquiry that under-fives are completely absent from the Government’s plans, yet that is a time in a child’s life that determines their life chances and life outcomes. Clearly, this is very much a gaping hole that needs to be addressed.

Psychosis: Early Intervention

Debate between Baroness Berger and Norman Lamb

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.