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Westminster Hall

Tuesday 17 April 2007

[Mr. Bill Olner in the Chair]

Mental Health

Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Michael Foster.]

9.30 am

Dr. Vincent Cable (Twickenham) (LD): I appreciate the opportunity to introduce this debate for several reasons, the first being that it is national depression awareness week. I do not know whether Government managers were aware of that when they scheduled the Second Reading of the Mental Health Bill, or whether the Speaker’s Office was aware of it when my name was drawn out of the hat for today’s debate, but I learned of it in the course of preparing for this debate. The event is organised by SANE, the mental health charity, and by the Depression Alliance. Sadly, I suspect that not many hon. Members or anybody else is aware of it. One of the underlying problems with mental health as a political issue is that it does not have a high profile, so I am doing all I can to raise it.

The second reason that I welcome today’s opportunity is more personal. Like other Members of Parliament, I am struck by the number of people who come to me for help with problems arising from mental illness. Large numbers of people come to my surgery for advice on problems with incapacity benefit that are linked to mental illness; many neighbourhood disputes or episodes of antisocial behaviour have at their root someone in a community who is unable to contain the symptoms of their mental illness. I have heard some heart-rending personal stories. I give the following examples because I undertook to the families involved that I would try to raise the profile of their cases.

One lady, Mrs. Knox, whose daughter committed suicide, wrote to the Minister of State, Department of Health, the right hon. Member for Doncaster, Central (Ms Winterton), and to the Secretary of State for Health stating:

Mrs. Knox wrote to Ministers and to me in the hope that somebody in the Department of Health would take notice. Her case is not untypical. Her daughter was schizophrenic and was well dealt with by clinicians, but she was then released into the community. Mrs. Knox believes that her daughter would still be alive if the sheltered accommodation that is available to elderly people as a matter of course were available to people with mental illness.

David Taylor (North-West Leicestershire) (Lab/Co-op): I congratulate the hon. Gentleman on obtaining this debate. I have an interest to declare: I am a patron of a befriending scheme for mental health patients in North-West Leicestershire.

Does the hon. Gentleman agree that schizophrenia is one of three conditions—anxiety and depression are the other two—whose sufferers benefit greatly when given psychological therapy within the NHS? A report
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published some time ago, “We Need to Talk”, urged greater resources and targeting of waiting times for access to such treatment. I do not know whether his constituent was waiting for access to support or psychological therapy, but it would be helpful if the Chancellor and the Minister were to announce a higher priority for such treatments today, to add to what is a good record on mental health over the past 10 years.

Dr. Cable: As it happens, the case to which I referred was more acute and therapy would probably not have been beneficial, but the hon. Gentleman is absolutely correct. I shall devote a substantial chunk of my comments to what has become known as the Layard plan, which is designed to build psychotherapy up to be a more central part of mental health treatment. The hon. Gentleman is right to emphasise its importance.

The second case I wish to mention to illustrate the importance of the subject involves some long-standing personal friends whose children went to school with mine. As their son grew up, it was discovered that he had serious mental health problems that were later compounded by alcoholism. Not untypically, when he approached mental health services, they would not deal with him because of his alcohol problem; he went to alcoholism services, but they could not deal with him because he had a mental health problem. He finished up in prison and, like many others in our overcrowded prisons, he should not be there. He should be dealt with by mental health services, but they are not structured to help him.

Susan Kramer (Richmond Park) (LD): The examples that my hon. Friend has given are of individuals with mental health illness within families. Does he agree that in many cases severe mental health illness impacts on a whole family, not only on the individual with the clinical problem? Is he aware that, since a ruling by the Law Lords a year ago, the courts have been unable to refer families whose members are suffering severe mental health disorders for treatment at specialist centres such as the Cassel hospital in my constituency? As a consequence of the ruling, the Cassel and other hospitals report that a significant number of children are now being placed in local authority care or are being put up for adoption, because their families are not receiving support and treatment.

Dr. Cable: That is clearly an important point. I was not aware of the specifics of the case that my hon. Friend mentioned, but I am grateful that she has brought it to our attention. I shall refer later to the Cassel hospital, which is one of the institutions that are under financial pressure.

The final personal point relates to my own family. One of the difficulties that people have with mental health is that they are coy about discussing it because it carries a stigma. However, one in three families are touched by mental illness in some way. I still remember a particular day from my own childhood. I was 10 years old when my mother was taken off in an ambulance to what all my friends called the loony bin because she had what is now called post-natal depression. At that time the condition was not described in such sympathetic terms; people were described as “mad” or “loony” and that was it: one was stigmatised. The tradition of not wanting to talk about
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such conditions has remained, and so their prevalence is not properly understood. A further reason for the debate, therefore, is to bring out such personal experiences.

A third reason is to draw attention to some of the financial pressures in the system. The Minister will be very well aware of them and I shall address them in more detail later. Unfortunately they are also well hidden. Often the cuts that are currently necessitated are occurring through commissioning bodies rather than directly through providers, and those bodies are in turn shunting costs on to local authorities. Much of the pain and the impact is therefore not publicly displayed but exists nevertheless, and I shall describe the effects in my local area.

The final reason why I welcome the opportunity for the debate is because I am my party’s economics spokesman. It might seem odd to link economics and mental health, but the link is a strong one. That was highlighted by a fellow economist, Lord Layard, who drew attention to the enormous economic costs of incapacity benefit, the impact on the prison system, and so on. Throughout the debate I shall inquire as to the Government’s progress in implementing his recommendations.

One way to come to that topic is by stressing the sheer scale of the problem. My understanding of the professional data is that approximately 30 per cent. of all recorded illness now relates to a mental condition of some kind. One in every six adults has experienced clinical depression or chronic anxiety, and among those very large numbers only one in four is ever treated, so the problem is largely concealed. Moreover, the scale of the problem is not static, but growing. The Institute for Public Policy Research recently produced an interesting report which pointed out that in a 30-year period the number of young people and children with mental conditions has increased by some 70 per cent. The problem is extensive and is increasing in its share of the sick population.

There are massive economic implications. A good illustration of that is in a parliamentary answer given to my hon. Friend the Member for Inverness, Nairn, Badenoch and Strathspey (Danny Alexander), who asked a few weeks ago for data from the Department for Work and Pensions on incapacity benefit claimants. Various points emerged from the data, including the fact that now almost 1 million people are on incapacity benefit because of mental illness, and 30 per cent. of all new applicants are people with mental illness. Even more striking was the statistical breakdown of that large number. Some three quarters—755,000—are people who have been out of work for more than a year. Yet more striking was the nature of their conditions. Approximately 377,000—about half of those on long-term incapacity benefit—were people with depression, and about a quarter, or 160,000, suffered from anxiety and neurotic conditions. The mental illnesses with which we are more familiar, and which are perhaps more dramatic, such as schizophrenia, were way down the list. There were about 36,000 schizophrenics.

The vast majority of people who are out of work, on benefit and unable to enter the labour market are suffering from conditions that are normally regarded as treatable—depression and neurotic conditions. Lord
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Layard, who did an analysis of the economic aspects of the problem, concluded that the direct cost to the Government of the number of people currently out of work and on benefit with treatable conditions was probably of the order of £9 billion, and that the cost to the economy as a whole indirectly was probably £25 billion, because of course many people are working but suffer high rates of sickness and therefore lower productivity. Therefore high economic costs are associated with mental illness.

As an economics spokesman I am naturally attracted to the idea that there may be ways of spending more money through the NHS to get savings rather than simply additional outlays. On the basis of that explanation, I want to develop further the arguments that Lord Layard put forward, and to pursue with the Minister how far the Government have got in taking the recommendations on board and implementing them.

Dr. John Pugh (Southport) (LD): I am not as familiar with the problem as my hon. Friend, but there is a distinction between those who are depressed and therefore unemployed and those who are unemployed and depressed as a result. Did Professor Layard offer an analysis of the difference?

Dr. Cable: I think that he did, and that he recognised a circular process. However, the key point was that the conditions are potentially treatable. Although Lord Layard is not a clinician—he is an economist, like me—he drew on the professional literature to demonstrate that psychotherapy in particular can be used to good effect with many of the people concerned.

There is obviously a need to take care in using such arguments; there are cases in which psychotherapy does not work and where drugs may be more appropriate. Evidence and clinical advice should provide guidance on that; it is not a subject for amateurs. However, the key point, which research by the National Institute for Health and Clinical Excellence has reinforced, is that there are many cases of depressive conditions that are best dealt with by psychotherapy, which takes us back to the intervention by the hon. Member for North-West Leicestershire (David Taylor). There are two reasons for emphasising psychotherapy. One reason is economic: Layard’s figures suggested that the cost of a 16-session course, which was regarded as about right for many people, would be about £750. The cost of remaining on invalidity benefit is about £750 a month, so the cost-benefit position is clear. The second reason is that patients greatly prefer psychotherapy to drugs. There is little doubt about that, thanks to the many surveys about choice and about patients’ attitude to mental health treatment. Indeed, one of the reasons why so few people are treated is fear of drug treatment. If patients are offered psychotherapy they are much more likely to come forward.

The problem arises when that basic and apparently sensible argument is contrasted with the reality, which is that there are very long waiting lists for psychotherapy; on average they are six to nine months, but they can be as long as two years. Surveys of GPs show that nine out of 10 doctors prescribe drug treatments, even though they are aware that psychotherapy would be more effective. Only one in 10
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mentally ill patients sees a psychiatrist within a year, and one in 20 sees a psychologist within a year. There is an enormous gap between our understanding of best practice and what actually happens. To remedy that, Layard produced a programme, which he recommended to the Government through the Cabinet Office, involving the training of 8,000 extra therapists and establishing evidence-based psychotherapy units in each primary care trust to develop the programme at local level.

The Government responded positively. At the beginning of last year, the Secretary of State indicated that the Government had taken the recommendations on board, wanted to see them carried through and had commissioned two pilot studies. What has happened and where are we going? I asked that of my local mental health trust and its members simply rolled their eyes and said that they did not know what was going on. It would be helpful if the Minister explained where the pilot studies have got to, whether they will be rolled out, where the training programme has got to, what is a realistic objective for the 8,000 therapists—if that is the number that the Government are working towards—and when people in the field can expect the new approach to bear fruit.

There is a link between that specific issue and the more general question of how financial cuts in the NHS impact on mental health. Clearly, if mental illness is increasing proportionately, relative to other illnesses, one would have thought that it should take a larger share of the NHS budget, which would reflect the Government’s general philosophy of shifting to preventive treatments. However, since 1997—I am sure that the Minister will confirm this—the proportion of NHS spending given to mental health has shrunk from 14 per cent. to 11 per cent. today.

There is a lot of evidence of financial stress in mental health services. The Minister has acknowledged that 11 our of 84 mental health trusts are under financial pressure, and I hope that in view of all the evidence presented to her she acknowledges that the problem is, in fact, much more widespread. SANE pointed out that in May 2006 it was calculated that deficits had resulted in £30 million of cuts across mental health services, which have now doubled to £60 million. In July 2006, a report revealed that 68 per cent. of finance directors of mental health trusts believed that cash was being diverted to bail out primary care trusts that had overspent. At the end of July 2006, David Nicholson, who was then head of the London strategic health authority, outlined savage cuts to mental health services throughout the capital.

David Taylor: The hon. Gentleman is recognised throughout the House as being fair and objective. He referred to 14 per cent. of the 1997 spend going to mental health services. Does he acknowledge that that spend has now doubled in real terms and that 11 per cent. of it is still an increase of more than half in real terms? I accept the hon. Gentleman’s general thesis that the proportion should be higher, but to attribute stress and pressure to budgetary problems when the budget has increased by almost 60 per cent. in real terms is a bit harsh.

Dr. Cable: I do not entirely share the hon. Gentleman’s optimistic interpretation. We know that the cost of clinicians in particular has risen
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substantially and has absorbed much of the real-terms increase, and it is not clear that the increase has fed through into service provision. In fact, the opposite is probably the case.

The Government’s response has often not been satisfactory. At Prime Minister’s questions some months ago I asked about the impact on my local area and drew attention to the fact that mental health provision and provision for people with learning disabilities were being cut back. The Prime Minister’s response was that there are many more doctors and many more hospitals. However, there has been contraction in the specific area of mental health. The trust in my area—Richmond—was not included among the 11 trusts that the Minister acknowledged. The mechanism by which it is happening is real.

Tim Loughton (East Worthing and Shoreham) (Con): I am grateful to the hon. Gentleman and agree with the points that he is making, particularly on financing. It can only add to the stigma attached to mental illness if the funding for mental illness is advanced disproportionately relative to the funding for physical illness. Does he acknowledge that the number of completed episodes of mental illness treatment and patients has been falling too? A lot of money has gone into the extra costs of employing agency staff because of the disproportionately higher number of vacancies among qualified mental health professionals. Therefore, disproportionately less money is being spread more thinly on fewer patients.

Dr. Cable: I was not aware of the precise details, but the hon. Gentleman has made the point well. In addition, demand is increasing rapidly at a time when the number of treatment episodes has been declining, so the gap is widening.

I imagine that the process in my area is common throughout the country. The primary care trust, which is well managed and runs surpluses, has found that the surpluses are being top-sliced and transferred to other parts of the NHS. That has been covered by a substantial chunk of the deficit having been offloaded on to the mental health trust, which has had £800,000 taken out of its £21 million budget. The mental health trust has dealt with this in two ways. First, it has shunted the costs on to the local council, which is not in a position to absorb them. The main consequence of that is a decline in the services for the elderly chronically mentally ill, such as people with advanced dementia who were given continuing care. The second way in which the cuts manifest themselves is that the requirements under the national health service framework to create outreach and support for people in their home, which is a positive initiative, are operating at a skeletal level. Local mental health trusts do not have the resources to improve that.

In practice, cuts are taking place, but they are neither visible nor dramatic, so they will not lead to banners in the streets. They are not like hospital closures. The elderly mentally ill will not be marching down the high street. Indeed, perhaps those are the reasons for what is happening. They are largely invisible, but they are very painful and real cuts in service provision.

I wish to round off my remarks with some specific questions about the Layard proposals and general financing. In their analysis to follow up depression
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awareness week, SANE and the Depression Alliance deal with how general practitioners operate. Most diagnosis is carried out at GP level and there are many deficiencies. SANE is asking whether the Government are looking again at the GP contract to ensure that doctors have a maximum incentive to produce prompt and efficient diagnoses of mental illness to get around at least some of the delays within the system. Is the Minister looking at the GP contract in the light of the professional criticisms that have been made?

I do not think that anyone argues now for institutional care on a substantial scale, but we acknowledge that care in the community has often not worked because of the lack of back-up. My constituent, Mrs. Knox, has asked whether there has been a concerted attempt to provide more sheltered accommodation for people with mental illness who have left institutional care and who need much more support than is provided traditionally by the mental health teams that visit someone’s house once or twice a month. Do the Government monitor such matters? Are they encouraging action in any way?

A third issue relates to co-ordination. The Minister has a role not only in the NHS itself, but in co-ordination with other Departments. How does the right hon. Lady approach the linkages with the Department for Work and Pensions? We know that pathways to work is working well for many long-term unemployed, but it does not seem to work for the mentally ill. Has that approach to employment been revisited? Does the Minister have any proposals for revising it?

As a result of the problems with financing the mental health sector, we are discovering the difficulties arising out of the localisation of decision making. We are now operating in a more decentralised mode, which is very welcome. There is greater emphasis on primary care trusts making their own decisions locally. However, the problem is that some local providers such as councils, which are democratically and locally accountable, and mental health trusts and primary care trusts acting as commissioning bodies, which are not, are shunting costs and responsibilities between themselves to avoid accepting the responsibility for the difficult choices that have to be made. How far is the Minister helping to produce greater coherence at a local level to ensure that mental health budgets are properly managed between local authorities and primary care trusts, and that there is an overarching local accountability through local authorities? What we are seeing at a local level is simply a shifting of responsibility from one body to another, with the elected bodies being landed with the worst of the difficult choices that have to be made.

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