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Mental Health Services (Cambridge)

1 pm

David Howarth (Cambridge) (LD): I am grateful for the opportunity to bring to the attention of the House and the Government what is happening to funding for mental health services in Cambridge. The situation is grave: cuts of 14 per cent. are proposed. Patients, their relatives and friends and others in the wider community are extremely distressed. The cuts threaten the whole of the service—acute hospital treatment, rehabilitation, day centres, the young people's service and even the treatment of those with dementia.

As Lord Layard recently said, mental illness is the equal of poverty as a source of misery in our society. Half the people on incapacity benefit are suffering from mental illnesses. Of the 5 per cent. of the population who are the least happy with their lives, 41 per cent. are mentally ill. More than one in six adults in this country suffer from a recognised mental illness of some kind. About one in 10 suffer from depression, some 4 per cent. from more serious personality disorders, and about 0.5 per cent. from the most serious illnesses—psychotic disorders.

Mental illness can be literally a matter of life and death. Between 70 and 90 per cent. of those who commit suicide are suffering mental illnesses. Major depressive illness massively increases the risk of suicide. However, as Richard Layard also points out, mental illness is avoidable. Drug treatments and various forms of therapy are becoming more and more effective. The time when mental illness was thought to be incurable has long gone, but there is still vast unmet need. Only about a quarter of those suffering from neurotic conditions—depression and anxiety—receive treatment and only 16 per cent. access community care services. It is even the case that 15 per cent. of people suffering from psychotic illness receive no treatment.

That is why what is happening to mental health services in Cambridge is so serious. Cambridge City and South Cambridgeshire primary care trusts are in deep financial trouble. They face a deficit of about £40 million. They have so far proposed £17 million of reductions. Of those cuts, £9 million will be in hospital services, £3 million in prescribing, £1 million in primary care and £4 million in mental health. That £4 million represents a 14 per cent. cut, of which £3 million is to be cut from the £23 million that Cambridgeshire mental health trust spends and the other £1 million from the voluntary sector and other mental health trusts.

An important point is that £2 million of the cuts have to be found before the end of the current financial year. That is an almost impossible task. The PCTs are consulting on how to achieve the savings. The main proposal is to close two long-term rehabilitation wards. Some of the patients would be transferred to another long-term rehabilitation ward, but that in turn would close in 2007. The PCTs expect those patients to be cared for in the community, and some investment is being made to try to make that approach work, as it can in the right conditions. However, my discussions with staff and experts in the field lead me to believe that about a third of the patients will certainly not be able to function in the community. Another third of them will have great difficulty in doing so and might well need readmission.
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The PCTs also propose to close 22 acute beds and a whole ward for older people. They hope that a reconfigured community outreach service will reduce demand for acute beds, but there is no way of knowing that such a reduction will occur. In some places where assertive outreach has been implemented, the demand for in-patient beds has risen, because previously undiscovered unmet demand has been revealed. In any case, Cambridge already has a precursor of the crisis-resolution home treatment service in the shape of the weekend service, and the PCTs propose to close even that.

The strain on community services will be increased by the PCTs' other proposals. One is to close a day centre in Cambridge. Another is to reduce the coverage of the young persons service so that it no longer helps 20 to 25-year-olds, even though, as I was told when I visited the service, 20 to 25-year-olds can often be more vulnerable than young people who are still at home. Finally, in a move that will appal Members who have been campaigning on the issue, the PCTs say that from January they will cease to fund a specialist service for patients with dementia. They are assuming that the National Institute for Health and Clinical Excellence will confirm its initial opinions about drugs that slow the onset of Alzheimer's disease, and the PCTs propose to cease to fund such drugs as soon as NICE confirms its view.

It is difficult to describe the pain and distress that these cuts will cause. All the professionals in the area will do their utmost to try to prevent adverse effects, but cuts of such magnitude must have a deleterious effect on all the services, not to mention the additional strains that will be placed on other local services and on neighbourhoods.

Tim Farron (Westmorland and Lonsdale) (LD): Is my hon. Friend aware of the British Medical Association's recent report that shows that of 530 health trusts in England, 385 were in deficit, and that those deficits amounted to £2.4 billion? In my constituency, the PCT is forced to propose cuts that involve the closure of two of the mental health wards at the Westmorland general hospital in Kendal: ward 2, which is for elderly mental health patients, and ward 4 for adult patients with mental health difficulties. That will mean that those people and their families will have to travel to Lancaster and Barrow-in-Furness to get treatment, which will further distress them and will undermine mental health services.

Perhaps my hon. Friend would care to reflect that if two thirds of the health trusts in England are in deficit, they cannot all be guilty of management incompetence, and that the Government should take responsibility for the crisis.

David Howarth : My hon. Friend makes the important point that what is going on is not just confined to one part of the country; it seems to be a more general problem.

Doctors already face the dilemma of whether they can start a new patient on a course of treatment that might lose funding before it ends. The stigma that still wrongly attaches to mental illness makes it difficult for those who need help now, or those who have been helped in the
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past, to campaign in the way that sufferers from other illnesses can. That means that it is more incumbent on Members of the House and others to take mental illness seriously.

Why is this happening? My hon. Friend alluded to that question. Cambridge City PCT points out that the funding regime has consistently worked against areas that are experiencing population growth. The funding formula has lagged behind reality, delivering resources to areas that have lost population rather than to areas that have gained population, as it should have done. I understand that, from next year, there will at least be a boost for areas such as Cambridge that form part of the Office of the Deputy Prime Minister's optimistically named sustainable communities growth areas. That is welcome, but it does not deal with the legacy of years of underfunding that has led to an historic deficit being shifted from year to year.

The PCT also points out that its finances are very badly affected by the presence of Addenbrooke's hospital, which is a large foundation hospital. Under the new funding arrangements in the NHS, foundation hospitals are, in effect, handed PCT chequebooks. They are entitled to be paid at fixed and non-negotiable rates whenever patients for whom the PCT is responsible cross the hospital's threshold and undergo treatment. The PCT, which previously negotiated a lower charge for the treatment, will now pay more for the same number of treatments. That system is the basis of the idea of patient choice, which will soon be implemented throughout the NHS. If our experience in Cambridge is anything to go by, patient choice will lead to a funding crisis in every service in the NHS, apart from in hospitals. Primary care, prescribing budgets, public health and mental health will have to bear the brunt of the new system.

More directly relevant to the crisis in mental health funding in Cambridge, however, is the way in which central Government calculate mental health need. The relative share of mental health in overall funding has fallen, and the Government's index of mental health need discriminates unfairly against Cambridge. It looks as if the index follows what is known about the subject; research shows that mental health problems are associated with low levels of education, low income and low housing tenure. The mental health index does indeed include measures of education, income and housing, but examination of the detail reveals serious problems and distortions.

The research shows that poor mental health is associated with being a tenant as opposed to being an owner-occupier. Some researchers speculate that the real driving factor is wealth, rather than housing, but the housing measure used by the mental health index is about the condition of housing rather than tenure. It is the wrong measure for mental health purposes.

The research also shows that housing tenure is a more powerful factor than education. A study on suicide rates across Europe, which was published in The British Journal of Psychiatry earlier this year, points out that in most countries, a well educated tenant has a higher risk of suicide than a less well educated home owner. The current mental health needs index, however, makes education a more important factor than housing.
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The situation is similar in relation to income levels. The measures of income used in the index are based on benefit take-up in the late 1990s. That is not the same as income now. An obvious example that affects Cambridge is the overwhelming majority of students who are on low, even negative, incomes, but who will count as rich people in the mental health index because they are disqualified from claiming benefits. Moreover, some factors, such as lack of social support, which research suggests are important for predicting mental illness, do not appear in the index. Areas in which the population is transient will usually have lower levels of mutual social support—a factor that should be in the index. At the same time, the index uses some factors, such as the serious illness ratio and the comparative mortality ratio, which do not figure strongly in the academic research as risk factors for mental illness.

A final point that affects Cambridge in particular is that the index counts proximity to a mental health hospital as a factor that reduces the cost of delivering the service, whereas experience in Cambridge is that the existence of a well regarded local facility tends to produce migration to the area of people who need that facility. The cost of providing care might be lower if there is a facility nearby, but there are also far more people who need that care.

I plead with the Minister to take action to prevent the cuts in mental health services that Cambridge faces. The PCTs' funding is inadequate, and the mental health needs index is inaccurate and unfair. The time scale for the cuts is utterly unreasonable. There is still time to prevent the suffering that those policies will cause.

1.14 pm

The Parliamentary Under-Secretary of State for Health (Caroline Flint) : I congratulate the hon. Member for Cambridge (David Howarth) on securing this debate on the funding of mental health services. I understand that his predecessor, Anne Campbell, a former colleague of mine, is to become chair of Cambridge's mental health trust.

I very much appreciate the interest that the hon. Gentleman takes in mental health because mental health is not often mentioned when we ask the public to name their priorities for NHS spending. That is why the Government took a different approach to mental health services when we were elected in 1997. Mental health was identified as a key clinical priority in "Saving Lives: Our Healthier Nation", published in 1998. The first ever national service framework was produced for mental health in 1999; and in 2000 the NHS plan set a comprehensive range of targets for the modernisation of mental health services. That is very important in relation to today's debate.

As a constituency MP, I know that for many years generations have tried to hide those with mental health problems behind institutional walls and away from the public gaze. In the last decade or so, however, there has been a change of view, partly resulting from the fact that the range of issues associated with mental health is vast. The issues cover all age groups, and some are more prevalent in certain groups—among men or women, among various ethnic groups and so on. We therefore need to take a flexible approach.

We want a system that allows residential provision and hospital treatment when necessary. However, in many circumstances, crisis episodes that have resulted in
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people being placed in hospital or seeking hospital services could have been resolved if we had had more outreach services in the community. We have considered how to modernise the service, seeing mental problems not only as a health issue but as an education issue and even a local authority issue. Just as important, it is a matter of social inclusion. For instance, further education colleges and other community facilities should be available for all; just because someone has a mental illness should not mean that, if appropriate, they cannot gain access to those services, like everyone else in the community.

We have had to consider how to improve access to effective treatment and care, reduce unfair variation, raise standards and provide better and more convenient services more quickly. The report of Louis Appleby, the national director for mental health, on the implementation of the national service framework for mental health illustrates the progress that has been made since the publication of the framework in 1999. The report shows increasing investment, which has resulted in improvements in the provision of mental health services, particularly those in community settings.

At the end of March 2005, there were 343 crisis resolution teams, against our target of 335. I know that the development of more crisis resolution teams is a priority in Cambridge. That will prevent people having to be placed in hospital; if it can be done, it is better to resolve problems in the community, for the individuals and their families. It is also better for the various agencies that may have a part to play. There were also 109 early intervention teams, more than double our target of 50; there were 1,520 community gateway staff, three times our target of 500; and 262 outreach teams—again, significantly more than our target of 220 in England.

Although some targets are yet to be achieved, it is clear that services have made real progress in improving the provision of services, particularly in the community. I was looking at how the PCTs, the partnership trusts and Cambridgeshire county council have dealt with some of the issues on housing. For example, they have opened an innovative supported living scheme with eight one-bedroomed flats in Cambridge city for older people with functional mental health problems; they have worked with the district council to gain planning permission for a 14-place supported living scheme in south Cambridgeshire for people with mental health problems; and they have developed a mental health accommodation forum, linking with mental health housing providers and many other partners to tackle one of the problematic areas for those who seek treatment. People living rough on the streets find it difficult to get effective treatment. Some of those matters are important and are part and parcel of having effective services for those who need them.

Funding is allocated to primary care trusts on the basis of the relative needs of their populations. It is always difficult to come up with the right formula that fits many different situations. However, a weighted capitation formula is used to determine each PCT's target share of available resources, to enable similar levels of health services for populations in similar need to be commissioned.
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Over the current three-year period, the total allocated to PCTs will increase by £12.7 billion or 30.8 per cent. Cambridge City PCT's allocation will grow by 29.1 per cent.—£27.8 million—to £123.4 million for 2005–06. Those are pretty substantial increases for PCTs to decide how to allocate. It does not stop there: this particular PCT will receive allocations of £148 million in 2006–07 and £160 million in 2007–08. That represents a cash increase of 17 per cent. over the next two years. That is a significant level of investment and it should deliver real benefits and results.

It is for PCTs, in partnership with strategic health authorities and other local stakeholders, to determine how best to use their funds to meet national and local priorities for improving health, tackling health inequalities and modernising services. We are often accused of being a centralising Government, but we recognise that we cannot micro-manage the health service from the centre. We can ensure that we have given increased resources—which we have—and that we offer advice and support on best practice, drawing the attention of local communities and PCTs to good practice elsewhere. Where possible, they should take all of that to develop local services that are fit for purpose. We are now pursuing a way to strengthen patient involvement in the development of services and working to avoid unnecessary admissions to hospital by improving community health services. Members would understand why, as Public Health Minister, I approve of that policy direction.

I understand that the trust is currently developing crisis intervention and home treatment services, assertive outreach services and more appropriate long-term accommodation for those who need it. That will mean that the trust will be able to reduce the need for adult in-patient beds. I am also assured that continuing hospital care will be available where it is most appropriate. Clinicians will be working with all affected patients and families to ensure that the most appropriate care packages are in place to meet their needs.

The development of new sheltered accommodation in Huntingdon and Peterborough will lead to a reduction in the need for rehabilitation beds in Cambridge. Patients will be able to be housed in accommodation nearer to their homes. The trust has also been developing other services within the community, including support services, services to carers and an increase in psychological therapy services through the employment of primary care graduate workers.

NHS bodies must live within their means, and sometimes that will lead to NHS organisations being faced with difficult decisions. As I said, it is right that decisions about the local configuration of services should be taken locally, where the health needs of the local population are best understood and local representatives and the public can make their voices heard.

The trust is currently forecasting a deficit of about £2 million, out of a total budget in excess of £83 million, for the current financial year, if nothing is done to address the issue. I understand that the mental health trust has been engaged in a financial recovery plan since July 2005; the PCT has been implementing a recovery plan for 18 months. The major part of the trust's current financial pressure comes from the deficit inherited from
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its predecessor organisations. That is being addressed through its financial recovery plan, and the trust's November board meeting will consider whether any further measures are required.

The financial situation that the local PCTs are dealing with is clearly putting pressure on services. I should reiterate that we are increasing funding to the NHS to record levels, and we believe that it is distributed fairly.

There are 15 proposals being consulted on and I am aware that the consultation process was launched on 10 October. I am sure that the hon. Gentleman will take an active role in that both as an individual MP and by galvanising his constituents and groups to participate. Of course, it would not be appropriate for me to say too much about the actual proposals, but I have had a look through the consultation document to see the range of different ways in which service provision is being considered. I hope that the hon. Gentleman will at least agree that there is much food for thought in the proposals both for in the hospital and out of it and which specialist day services are necessary, as opposed to, for example, making sure that the other mainstream providers of education, leisure and so on are open and accessible to those with mental health problems and issues.

The consultation document published by Cambridge City and South Cambridgeshire PCTs outlines a range of proposals for the future of mental health services in Cambridge. The proposals are in line with the PCTs' and the trust's shared vision to continue to modernise services in accordance with national guidance, including the national service frameworks. The proposals have been developed through a mental health project board, which includes representatives of the local PCTs and the trust. It is not, dare I say, just administrators applying their thoughts to the scheme, but it involves the people who work with those for whom mental health is part of their lives, and listens to what they have to say.
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I am reassured that the consultation is and will continue to be handled in an open and inclusive way. A number of public meetings have been arranged to enable proper discussion of the proposals with stakeholders and local people. The local health community has recognised that the development of new services, in line with the national service framework for mental health, will mean that some traditional services could be—should be—reduced or closed. That debate has to be held locally. The experience is in keeping with that of other mental health services across the country. Although I understand local concerns about mental health services, and what people have got used to, we need to develop an efficient, affordable and effective modern service for the future. I am reassured that the proposed changes are being properly consulted on, and I hope that the hon. Gentleman will appreciate that the decisions following the outcome of the consultation must be made locally. It is not just about cuts in spending, but about making sure that we have services that are fit to purpose. More than ever before, there should be wider link up with local authorities and others who can play a role in determining those services in the future.

In conclusion, the consultation is under way. I hope that as many people as possible will take part. It is important that people's views are fed into the consultation; it is also important that they have the opportunity to have matters explained, as in such situations people often do not understand why things are happening. That is important for public understanding. I have seen in Cambridge and the surrounding area that the PCTs are very responsive to the needs of mental health service users and to the services provided. That said, there is also an understanding that in certain areas there has to be more community development, and the consultation gives a chance for all involved to have their say and to help to construct and be the architects of a better service in the future.
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