Mental and Physical Health: Parity of Esteem

Lord Carlile of Berriew Excerpts

Thursday 10th October 2013 Lords Chamber

[Lord Carlile of Berriew (LD)]

My Lords, the noble Lord, Lord Layard, has taken a long and influential interest in mental health; not least as a leading economist, he has made a powerful economic case for parity of esteem. We are very grateful to him for securing this debate.

I notice that the noble Lord is sitting alongside the noble Lord, Lord Bragg, on what I suppose one could describe as the polymath Bench this afternoon. This morning, the noble Lord, Lord Bragg, presented a most interesting Radio 4 programme featuring the life of Galen, the extraordinary second century Roman doctor. Galen discovered many things about medicine. One was that he realised that much of the variation in physical health and in human behaviour can be explained by temperament and stress, as he put it. He identified the inseparable links between physical pathology and psychopathology 1,900 years ago. To some people suffering from mental illness in this country and in particular to those who live with them, it can sometimes appear as though little more has been learnt in the past 2,000 years.

Of course, that is unfair. Generally speaking, huge advances have been made in the treatment of mental illness. Drugs are available which, for example, have vastly improved the quality of life for patients suffering from bipolar disorder and, more recently, for patients suffering from acute schizophrenia and other conditions. Therapies, not always involving drugs, have had a remarkable and beneficial impact on many individuals—albeit, I am afraid, with patchy availability in this country. I had the privilege of serving as Member of Parliament for a constituency in rural mid-Wales for some years. This is a bit historic, but even today I understand that the availability of therapies is very uneven in an area like that. You can get a therapy, but not necessarily the right therapy. Providing the correct therapy is extremely important.

The stigma of mental illness remains an obstacle to progress. The fear of telling an employer of a psychiatric diagnosis remains much greater than revealing a physical illness, however serious. In my own legal profession, I have seen careers destroyed by a psychiatric illness of limited duration, whereas a physical illness of similar duration has been received with sympathy and patience and people have been able to return to practice.

There has been some progress. The media have taken a commendable lead. I do not only listen to the noble Lord, Lord Bragg, on the radio; sometimes I watch television drama. Storylines in recent crime noir series, in “Homeland” and elsewhere, have highlighted that anyone, including the at least apparently heroic, can suffer from a mental illness and still lead a perfectly normal life and provide service to society.

Recently, I enjoyed the privilege of co-chairing with Professor Dinesh Bhugra an investigation for the Mental Health Foundation into the future of mental health services. Our report, Starting Today, was produced last month. There is not enough time in a debate such as this to go into the detail of the report, but one of its foundations was pleasure at the 2011 English mental health strategy, which rightly committed this country to parity of esteem. However, the declaration, welcome as it is, has not been matched by progress, which has been variable and not yet quick.

The Mental Health Foundation report has headlined a number of issues which could develop parity of esteem in the coming years. I will refer to a few of them. We certainly took the view that we need to look at fresh ways of implementing known best practice alongside developing technology. Above all, I would like to highlight mental health in primary care. GPs should become—but in only a few cases have become—leaders in mental health care, providing quickly accessible services in their surgeries.

I referred earlier to rural mid-Wales. I know of one practice which years ago introduced a psychotherapist into the health centre in a small Welsh market town. It had a remarkable effect. It meant that the doctor could say to the patient, “I think you need to go down the corridor and talk to my colleague”. An intervention was made which beneficially affected the life of the patient concerned. We need to see more of that. By the way, a two-week wait for an appointment with a doctor just will not do for someone suffering from a growing mental condition. GPs need to know as much about mental illness as about physical illness. So far as possible, primary and secondary mental health services should merge to produce early treatment and the value for money that the noble Lord, Lord Layard, has identified in some of the work he has done over the years on mental health.

The Mental Health Foundation report also found that there is value in self-management. So far as possible, patients in a personalised service should be encouraged to take training in the management of their own care in partnership with therapists and clinicians. A stake in your own recovery is a real incentive for a person who is suffering from mental health problems, but it needs some formal help.

Turning to crisis care and community support, every accident and emergency facility should be equipped to deal with emergency mental health issues, to be followed up by community support. They are not. All over the country, they are not equipped. That is not acceptable.

On collaborative working, I emphasise something that I have encountered in other areas, such as child safeguarding, which is the sharing of information. When somebody with a mental illness goes into an accident and emergency department, a solicitor’s office, a police station or a school, they go into a silo. That is not acceptable. Data protection is used as an excuse for not sharing information. Actually, it is near criminal not to share information for people who have needs that are demonstrated by mental illness. We must ensure that those who have information to share do not sit in silos and that the ability to pool funds from different funding streams into a single integrated care budget, shared protocols and partnership agreements, co-location of services, multi-disciplinary teams and liaison services becomes a reality.

The Mental Health Foundation report also emphasised the beginning and the end of life as key areas where mental health interventions should be made available quickly and fully. Early interventions in schools can identify mental health issues that affect not only the child but the child’s parents and carers. Many cases have been highlighted in some terrible reports that have been produced after fatal events that show that to be the case.

The final issue that I want to raise in the time available concerns the elderly. Perhaps this is an issue that we can raise comfortably in your Lordships’ House because so many of us are OAPs these days. There is a growing issue, as we all know, about elderly care. Many of us have enjoyed having parents who lived into their late 90s and indeed, happily, there are Members of this House in their late 90s, but we know that this issue needs a great deal more work than it has received. It will enable elderly people to lead a full life albeit while suffering from some incipient dementia.

There are many challenges and this debate highlights them. It allows us to show Parliament’s determination that parity of esteem should be a must and not merely a phrase.

Health: Anorexia

Lord Carlile of Berriew Excerpts

Monday 25th February 2013 Lords Chamber

[Lord Carlile of Berriew]

I congratulate the noble Lord, Lord Giddens, on initiating this debate. I agree with everything that has been said so far. This is an extremely important subject, which we should address more often, both in this House and in another place. In a very densely packed sentence in its College Report 170 of 2012, the Royal College of Psychiatrists said:

“Eating disorders are serious mental disorders with high levels of physical and psychological comorbidity, disability and mortality”.

It is not just a free-standing condition, in other words.

Anyone who has ever been close to a serious eating disorder knows that it can prove extremely debilitating to the whole family in which the sufferer lives. Indeed, it is an ordeal for families that can lead to permanent effects, even if the person concerned appears to recover, although there can be and sometimes is good recovery. If there is to be good recovery, it is vital that there should be early interventions, which must be the right ones—not just any intervention. In too many parts of the country, the wrong intervention is provided because the services needed for that person are simply not available. If a sufferer from anorexia needs cognitive behavioural therapy, it may damage them to give them drugs, and vice versa. It is a very subjective illness.

My perception of how the illness is treated throughout the United Kingdom is that it is very unevenly dealt with. For a number of years, I was a Member of another place for a constituency in rural Wales. Today, as then, the services available in rural Wales—in an area affected by its rurality—are far less clear and certain than in many urban areas.

In opening the debate, the noble Lord referred to the internet and I agree with him entirely about its effect. There are far too many sites on the internet that worship the slender. I am shocked, too—for I still sometimes see teenage magazines in my household—by the primacy given to thinness in magazines. These are everyday, perfectly respectable magazines, purportedly edited by responsible people. With my children, stepchildren and grandchildren, who regard me as quite a decent sort of shopper, especially if there is a credit card in my pocket, I sometimes go into well known clothing stores. Some barely have anything larger than a size 10, yet that is a very small size which probably truly fits a minority of young women in their undieting state. It seems shocking that we are not capable of addressing in a more realistic way the natural state of our young women and young men.

I also believe that there is a complete failure in outcome monitoring, as the Royal College of Psychiatrists has said. We would have more consistent services if we knew the results. We even talk about paying for prisons by results but we do not pay for psychiatric services by results. It seems to me that one way of disciplining the relevant providers of services would be to judge their results. If they do not perform properly, someone else is available to do the job. The principles applicable to child safeguarding standards, which include removing child safeguarding from local authorities in certain circumstances, should also be applied to psychiatric and psychological services, especially those affecting eating disorders.

There are some innovative ideas around which really are not all that innovative. In some respects, it is a case of returning to what happened in the past. However, I suggest to your Lordships that annual medical examinations of every schoolchild, up to and including year 11, could be introduced. Looking around the House, those examinations were certainly undergone by everybody who is here today. Very simple and rudimentary checks, such as weighing, measuring and looking at teeth and feet, tell you an awful lot about a young person, especially if the figures can be compared with those taken a year or a term ago. I do not understand why we have abandoned these rudimentary measures, apparently on the grounds of cost, when any cost-benefit analysis shows that this kind of examination saves a great deal of money further down the line.

Finally, I wish to say a word in favour of school nursing and school health services. They seem to have been abandoned in an awful lot of educational institutions, yet the rumour mill that takes children to the school nurse saves lives. I wish we could look at that more closely for the future. There is a great deal to do and we do not seem to be doing it.

Health and Social Care Bill

Lord Carlile of Berriew Excerpts

Wednesday 8th February 2012 Lords Chamber

[Lord Walton of Detchant]

My Lords, in rising briefly to support the amendment so ably proposed by my noble friend Lord Patel and supported by the noble Lord, Lord Alderdice, I ask the Minister one very simple question. In Clause 1(1)(a) the Bill talks about the,

“physical and mental health of the people of England”,

and says that the health service must be “designed to secure improvement” in that health. What on earth could the objection possibly be to inserting in paragraph (b) at line 6 the unexceptional words listed in the amendment? They simply stress the crucial importance of mental as well as physical illness. How on earth could this be construed as doing any damage whatever to the Bill? It is something that I hope very much the Government can be persuaded to accept.

[Lord Carlile of Berriew]

My Lords, I should like to say a word on behalf of those who have had to care for family members—often a young member of the family—who have suffered from severe mental illness. Those who have suffered that experience—and I am one—know how marooned they feel when they find that someone in their family has a serious mental illness. If somebody has a broken leg, you can locate the leg and take the medicine. If somebody has even cancer, it may not be curable but at least you have the knowledge of the location or locations of the cancer and the topical treatment that is to be applied to it.

The problem for families who experience in their midst mental illness is that no medicine can be applied topically to the place where the hurt or illness is taking place. The prognosis is uncertain, the mortality rate is depressingly high and usually at the hands of the sick person, and accessing good health service facilities is quite chancy, I am afraid. There is a real postcode lottery with mental health treatment. If, for example, you live in a remote rural area, only some therapies will be available and they may be the wrong therapies, particularly if the patient is a child or adolescent suffering from serious mental illness. Therefore, I simply say to the Minister who, as has already been said, cares deeply about these issues, that the adoption of this very simple amendment, as the noble Lord, Lord Walton, rightly described it, would send out such a telling message of support to families who have to care for people who suffer, perhaps temporarily, from mental illness that it would be seen as a declaration of purpose by this Government.

[Baroness Whitaker]

My Lords, briefly, from a lay perspective, I urge the Minister to take this amendment very seriously. I will not rehearse what I said at Second Reading from my experience on the board of the Tavistock and Portman clinic or from other walks of life about how widely damaging and destructive it is not to have parity, and how it needs to be explicit parity to change culture and to erode the stigma and the neglect associated with mental ill health. If the Government are rash enough not to accept the amendment—and I am quite sure that the noble Earl is not like that—I hope that there will be a Division. If the debate lasts until five o’clock, when I am committed to chairing a meeting, I hope that the House will accept my apology but I will return to vote.

Health: End-of-life Care

Lord Carlile of Berriew Excerpts

Monday 16th January 2012 Lords Chamber

[Earl Howe]

My Lords, the end-of-life care strategy that we are pursuing, published by the previous Government, highlighted the need for a cultural shift in attitude and behaviour related to end-of-life care within the health and social care workforce. The noble Baroness is quite right that this is an issue. In partnership with the national end-of-life care programme, we have taken forward a number of initiatives to develop the workforce’s understanding. We have commissioned the development of an e-learning package, which is turning out to be popular, that includes advance care planning and communication skills. Core competences and principles for end-of-life care have been developed, and a number of pilots have been taken forward in that area. A document called Talking About End of Life Care: Right Conversations, Right People, Right Time has been published and was completed early last year. There are a number of initiatives in this area.

[Lord Carlile of Berriew]

Does my noble friend agree that the new NHS commissioning arrangements are such that they give an opportunity for advance directives to be collected and collated in a coherent way by general practitioners? Will he also confirm that, whatever advance directives are given, the need to provide comfort to patients remains a duty on clinicians?

[Earl Howe]

I agree with my noble friend on both counts.

Health: Pathfinders

Lord Carlile of Berriew Excerpts

Thursday 12th January 2012 Lords Chamber

[Lord Carlile of Berriew]

Can my noble friend confirm that the NHS will take fully into account the success of pilot pathfinder projects in places as diverse as Newcastle, Swindon and Bedfordshire so that the NHS itself encourages the development of pathfinder projects? Will he also take into account the fact that GP co-operatives were very successful as long as they lasted, but the discouragement they were given by the previous Government brought a disastrous end to some very good schemes?

[Earl Howe]

I am grateful to my noble friend. I think everybody agrees that integrating services, however one defines that—although the common denominator is surely from the point of view of the patient—is a good thing. We do not wish to lose sight of the lessons that have been learnt so effectively in the places mentioned by my noble friend. It is true that other areas have yet to catch up. We recognise that, and the focus over the next 12 months will be very much on sharing the lessons that have been learnt by the pathfinders that we know are working well.