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I can also give some assurances about technical insolvency, which I hope will be of some help. I am aware that many businesses have said that, despite this exceptional arrangement to spread payments, they will have to add this liability to their balance sheets. That will mean that they will become technically insolvent, and as a result, although they may be in a position to continue their businesses, technically they will have to cease trading. That is a serious matter. The department has taken advice from experts in the Insolvency Service and the Department for Business, Enterprise and Regulatory Reform. Clearly, the outcome will depend on the individual circumstance of each business on a case-by-case basis, but it will depend on the level of both the existing assets and liabilities when the backdated rates bill was received and the directors’ reasonable expectations of being able to meet their liabilities as they fall due in the future. The advice that the department has received is clear on the fact that the additional liability is not in and of itself a de facto reason for a company becoming insolvent. We want to ensure that that is widely understood, so that companies can continue trading where there is a reasonable expectation of being able to meet their liabilities in the future.
The substance of that was put in a letter from my right honourable friends John Healey and Stephen Timms to the Treasury Select Committee. I shall put that letter in the Library and I hope that noble Lords will feel that they can make use of it. We will also see whether we can put it on government websites so that it will be accessible. In addition, companies can of course get advice from legal support, qualified accountants, authorised insolvency practitioners and so forth.
I am sorry to have taken the time of the House at such length. Nobody would deny that this is an extremely difficult matter. It is one that we wish had not arisen and certainly not at this time. We do not deny that. We have done what we can do to assist within the current law and system of business rates. I hope that noble Lords who have spoken will accept that and will not press their case to a vote.
8.25 pm
Earl Attlee: My Lords, I am extremely grateful to all noble Lords who have taken part in the debate, particularly the Minister for making herself available at short notice for such an important issue. She has given us a much more detailed explanation of the problem than Parliament has had before from Ministers.
The Minister has skilfully tried to tempt me to withdraw my Motion but I cannot do so because it is accurate. The regulations will not prevent insolvencies from occurring. In the later stages of her response, the Minister touched on the insolvency issue, but I anticipated her response. Businesses will still experience the problems that I described. They will find it extremely difficult to raise finance. She also touched on seeking professional advice. In these circumstances, professional advice would be very expensive. The Minister pointed out that the regulations benefit not only port occupiers but the whole business community. That is just as well, otherwise the regulations would definitely fall foul of EU state aid rules.
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The Minister indicated that the problem is largely a commercial problem between the port operator and the port businesses. She is suggesting renegotiating a commercial contract after the supply of the goods and services in question, so that the port operator can pay money to the port business, even though that was not provided in the original contract. I do not know how many commercial negotiations the Minister has taken part in, but I fear that such negotiations might be a bit tricky. Moreover, I wonder how often central government have paid out money which is not due under a contract. I am certain that Ministers will have to do much more than the regulations provide for at some point in the future. The Minister explained how difficult and how complex these arrangements are; I accept it will not be easy but, at some point, more will have to be done. This is not the time to impose a huge, retrospective financial burden on businesses in an already fragile industry. I should like the House to determine this matter. I beg to move.
8.27 pm
Division on Earl Attlee's Motion
Addington, L.
Anelay of St Johns, B. [Teller]
Astor of Hever, L.
Attlee, E.
Barker, B.
Bates, L.
Berkeley, L.
Bew, L.
Brooke of Sutton Mandeville, L.
Byford, B.
Carlile of Berriew, L.
Carnegy of Lour, B.
Cathcart, E.
Chadlington, L.
Cope of Berkeley, L.
Craigavon, V.
D'Souza, B.
Elliott of Morpeth, L.
Fookes, B.
Geddes, L.
Goodhart, L.
Greaves, L.
Greenway, L.
Hanham, B.
Henley, L.
Hodgson of Astley Abbotts, L.
Hogg, B.
Hunt of Wirral, L.
Inglewood, L.
James of Blackheath, L.
Kingsland, L.
Knight of Collingtree, B.
Leach of Fairford, L.
Lindsay, E.
Linklater of Butterstone, B.
Liverpool, E.
Livsey of Talgarth, L.
Luke, L.
Lyell of Markyate, L.
Mar, C.
Mar and Kellie, E.
Marlesford, L.
Montrose, D.
Morris of Bolton, B.
Moynihan, L.
Northesk, E.
Norton of Louth, L.
O'Cathain, B.
Pearson of Rannoch, L.
Plumb, L.
Rennard, L.
Rogan, L.
St John of Fawsley, L.
Seccombe, B. [Teller]
Selkirk of Douglas, L.
Selsdon, L.
Shaw of Northstead, L.
Sheikh, L.
Shephard of Northwold, B.
Shrewsbury, E.
Shutt of Greetland, L.
Simon, V.
Skelmersdale, L.
Skidelsky, L.
Steel of Aikwood, L.
Sterling of Plaistow, L.
Stewartby, L.
Taylor of Holbeach, L.
Teverson, L.
Thomas of Winchester, B.
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Ullswater, V.
Verma, B.
Waddington, L.
Walpole, L.
Warsi, B.
Williamson of Horton, L.
Adams of Craigielea, B.
Andrews, B.
Archer of Sandwell, L.
Bach, L.
Bassam of Brighton, L. [Teller]
Bernstein of Craigweil, L.
Bilston, L.
Borrie, L.
Boyd of Duncansby, L.
Brett, L.
Brooke of Alverthorpe, L.
Brookman, L.
Cohen of Pimlico, B.
Corbett of Castle Vale, L.
Dean of Thornton-le-Fylde, B.
Desai, L.
Dixon, L.
Dubs, L.
Elystan-Morgan, L.
Evans of Parkside, L.
Farrington of Ribbleton, B.
Faulkner of Worcester, L.
Foster of Bishop Auckland, L.
Gale, B.
Gibson of Market Rasen, B.
Gilbert, L.
Gordon of Strathblane, L.
Gould of Potternewton, B.
Greengross, B.
Grocott, L.
Hart of Chilton, L.
Haworth, L.
Henig, B.
Hilton of Eggardon, B.
Hollis of Heigham, B.
Howells of St. Davids, B.
Hoyle, L.
Hughes of Woodside, L.
Hunt of Kings Heath, L.
Janner of Braunstone, L.
Jones, L.
Jones of Whitchurch, B.
Kirkhill, L.
Layard, L.
Lea of Crondall, L.
Lofthouse of Pontefract, L.
McKenzie of Luton, L.
Maxton, L.
Meacher, B.
Morgan of Drefelin, B.
Morris of Handsworth, L.
Morris of Yardley, B.
Myners, L.
O'Neill of Clackmannan, L.
Patel of Bradford, L.
Pitkeathley, B.
Prosser, B.
Quin, B.
Rea, L.
Rooker, L.
Rosser, L.
Rowlands, L.
Royall of Blaisdon, B.
Scotland of Asthal, B.
Sewel, L.
Snape, L.
Thornton, B.
Tunnicliffe, L. [Teller]
Whitaker, B.
Health: Cognitive Therapy
Question for Short Debate
8.37 pm
To ask Her Majesty’s Government what steps they are taking to implement cognitive psychotherapy in the National Health Service.
Baroness Tonge:My Lords, last weekend I was in Syria talking to Hamas leaders. It was very interesting. In the discussions, one of them said, “We love life and happiness as much as any of you do”. I thought that that was fairly profound stuff coming from a group that uses suicide bombers, but I shall save that for another debate. We all love life and happiness and that is what we all want. Sometimes people or events conspire to make us unhappy or sometimes, without any reason, people become depressed. Sir Winston Churchill had his black dog, which was not a bipolar disorder but just good old depression.
I am fortunate never to have suffered. I have been very sad, yes, frustrated, yes, suffered pre-menstrual tension, yes—you should have seen me in those days—but fortunately I have never been depressed. However, I have many patients, friends and relatives who have
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Depression and its stablemate anxiety are the most common mental health disorders. One in five people will suffer from them at some stage in their lives, with one in 50 suffering from severe depression. People are often reluctant to go to their GPs because, understandably, no one wants mental illness on their medical record—people are afraid that it will affect job prospects in the future.
As the economic situation worsens, more people are forced to face unemployment, debt and loss of self-respect, which can only make depression more likely. This problem is urgent. The treatments currently available are the talking therapies and drugs. Despite the National Institute for Health and Clinical Excellence asking doctors to use drugs with caution, they cost the NHS £400 million per annum.
I have always been enthusiastic about cognitive behavioural therapy, which from now on I shall call CBT. Long ago, I worked in a centre where it was being used. It seeks to teach people skills to tackle their problems. It needs well trained and experienced therapists, which the NHS does not have in great number. Everyone who needs a therapist should be able to access one, but I understand that in some parts of the country it takes up to 18 months for a suffering person to see a psychotherapist. That is useless and unacceptable. Last May, the King’s Fund found that one-third of people suffering from depression were not getting any treatment. That is a lot of human misery. Even so, the cost of treating depression—also according to the Kings Fund—is £1.7 billion per annum. The cost of lost employment is £7.5 billion per annum. The problem is urgent and escalating.
The Government have taken some important steps in recent years. They aim to make therapy more accessible and announced about two weeks ago that psychotherapy centres, to which patients will be referred directly, would be established in all primary care trusts. This will involve training 3,600 more psychotherapists. However, it takes about four or five years for them to become competent and the problem is more urgent than that; we do not have the time to train that many people.
The rather irritating fact is that the Government have had a partial solution at their disposal for some time in the form of computerised cognitive behavioural therapy. This, I emphasise, is useful for mild to moderate depression. At this juncture, I declare that I have absolutely no financial interest whatever in any company that provides software for these therapies.
In February 2006, NICE recommended that primary care trusts should purchase and use computerised CBT, and a treatment called “Beating the Blues” was recommended. It should have been available 90 days after recommendation; primary care trusts are obliged to provide their patients with what NICE recommends. It would treat 400,000 people each year, producing a cost benefit to the NHS of £126 million a year. Despite this, there has been only about 15 per cent take-up by the primary care trusts. To date, nine primary care trusts have complied with NICE guidance. It is another NHS treatment at the mercy of the postcode lottery.
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Many who have used “Beating the Blues” have found it very helpful in dealing with their problems. The Government have failed too many people who are suffering. The problem of depression is immediate and requires treatment now. The Department of Health has been offered a way by NICE, which approved “Beating the Blues”, to treat people as part of its access to psychotherapy programmes, but it has failed to take up the recommendation.
Ministers have given all sorts of assurances over the years. In March 2006, the White Paper Our Care, Our Health, Our Say included a commitment to support primary care trusts in delivering these computerised treatments. In November 2007, the national director for mental health, Louis Appleby, wrote to all primary care trusts reminding them of the obligation to provide computerised CBT by 31 March 2007. On 28 March 2007, Patricia Hewitt, then Secretary of State for Health, told us that patients would have this service provided by their primary care trust. In December 2008, only a few months ago, Health Minister Dawn Primarolo said that primary care trusts were obliged to provide funding for NICE-recommended computerised CBT packages.
So where is it? Why is it not being delivered? We get more and more announcements and commitments to mental health services, but this promise is yet to be delivered three years on. Alan Johnson has tried to be helpful by saying that patients who are dissatisfied with the non-availability of a treatment should take up their concerns through the NHS complaints procedure. In my opinion, an already mildly depressed patient might become very seriously depressed or even suicidal if they had to tackle the NHS complaints procedure. I had plenty of experience of that with my constituents in the other place.
The trouble is that government promises are not being delivered—period, as Tony Blair used to say. I appreciate that, in some sections of the profession, it will be said that a computer program cannot replace a face-to-face session with a trained psychotherapist. Maybe not, but it can replace a non-existent psychotherapist, which is currently the reality for most patients with mild to moderate depression.
This should not be a consideration in clinical treatment, but it is worth remembering that, in 2004, the noble Lord, Lord Layard, in his paper Mental Health: Britain’s Biggest Social Problem?, estimated that the cost then of a course of face-to-face CBT was £750, whereas, according to NICE, the computerised program that that body had approved cost £45. That is a huge difference. Help could be made available to far more patients. We must also remember that many young people who suffer from depression spend an awful lot of time with their computers. My young people certainly do; I sometimes think that Facebook has replaced the pub for some of them. We may sneer, but it is the most natural thing in the world for them to talk to a computer.
In conclusion, we cannot wait any longer for evaluations and reports to see whether greater access to CBT is being achieved for patients with mild to moderate depression. There is a proven treatment, but it is still not available in the vast majority of primary
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My colleague in the other place, Norman Lamb, has tabled an Early Day Motion on computerised CBT, which over 50 MPs have already signed—20 from the Minister’s own party. I look forward to the Minister’s assurance that she will rectify this problem and make the treatment available in all primary care trusts.
8.48 pm
Lord Layard: My Lords, this debate is extremely timely; I congratulate the noble Baroness on having introduced it. It is timely because of the recession that is now upon us, and which will do so much damage to the mental health of so many citizens of this country.
The goods news is that the Government, well before the recession was even dreamt of, had embarked on the programme to which the noble Baroness refers, which will revolutionise the availability of psychological therapy services in this country. I do not think that any of us are opposed to computerised CBT, as recommended by NICE as part of the stepped-care system; of course, it is one of the rather low steps. It has also required the participation of a living therapist for it to be effective in any of the evidence-based trials. For anybody with a serious condition, the human one-on-one treatment is essential. That is what the Government’s programme concentrates on.
In a debate on the future of CBT in this country we must focus mainly on CBT provided by live therapists to patients in the new way that the Government will make possible in this country. This is the most radical improvement in psychological therapy services ever undertaken. I am impelled by the fact that we are having this debate to say a little about some of the good things about it. I should declare an interest because I am a member of the programme management board. However, I then want to say a bit about its future, which is still not assured, because it depends on the upcoming Comprehensive Spending Review. Then I would like to say something about CBT for children, which is also a very major issue that still needs to be addressed properly.
Let me start with the scale of the problem, which the noble Baroness mentioned. Sixteen per cent of the adult population suffer from clinical depression or a diagnosable anxiety condition. Until now the main support available for these people has been non-specialist support from GPs, mainly in the form of medication. This is despite the NICE guidelines, which say that computerised CBT should certainly be available in the early stages, but also that one-on-one CBT should be available for everybody who suffers from depression or anxiety disorders that are not either very mild or very recent. As has been said, that has not been the case throughout the country, due simply to the fact that the therapists have not been available within the NHS to deliver it.
However that all changed from the announcement that the Secretary of State made in October 2007, when the Government committed themselves to creating
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The programme of training and rollout started in October and it is running well ahead of schedule. In two years from now over half the people in the country will have access to it, because of the grass roots enthusiasm which the primary care trusts have shown in responding to this challenge. I would just like to put in parenthesis that the pushing of computerised CBT preceded this programme, and was based on the assumption, to some extent, that this money would not be available. The noble Baroness has an important point about computerised CBT, but we have to realise that this programme supervenes the instructions that were given about that, and delivers hope of something much more serious than the computer can deliver.
How do we know that all this rollout is worthwhile? We know from randomised control trials, which show that at least half of those treated will recover from their conditions as a result of treatment. Pilots in the field have confirmed this success rate, and of course that means that not only will we get major humanitarian benefits from this programme, but we will also get—and we can do these calculations—a return to the Exchequer which would fully repay, in savings on benefits and lost taxes, the expenditure that is being made. So it is very important that we proceed with this programme at the centre of our effort to deliver CBT to the British population. We will know whether it is working because every session that a CBT therapist has with a patient will include monitoring the patient’s progress. This will not be money down the drain.
The problem is that the programme is funded for three years but after that there is no commitment. We are just coming up to the spending round in which that will be determined. It is vital that the programme continues until the whole country is covered, not just half of it, by these state-of-the-art services. We have therefore to ensure that in the next spending round the necessary growth in funding continues from 2011-12 onwards. We owe that to the people out there who are suffering.
In the pilots, the typical patient treated had been suffering from their condition for five years—five years of wasted life, when they could have had, with a 50 per cent probability, a complete transformation of their lives. We cannot allow that to continue. So I have a
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I should like finally to say a word on children. The programme that I have been discussing relates to adults, but of course many of those who suffer as adults also suffered as children. Child mental illness is even more tragic than for adults. It is also the source of so many of our social problems. Ten per cent of all children would be diagnosed as suffering from mental illness of all kinds, and 5 per cent from anxiety disorders for which the prime treatment is CBT. Of these children only a quarter are currently receiving specialist help or have seen a specialist in the past year. That is just not good enough. Although we have child and adolescent mental health services which in many cases are excellent, their capacity is just too small. There are many children in real need who get turned away or do not get referred because the waiting list is too long, and not all the services are delivered in accordance with the NICE guidelines.
What we now need is a strategy for expanding and upgrading CAMHS as well as adult services. A number of us have suggested a five-year plan which would train 200 extra child therapists every year and be adequately funded to pay local services for providing the on-the-job training within the NICE guidelines. I think that that would be a powerful formula. It would cost no more than £35 million by the final year of the next spending round. I very much hope that the Minister can undertake that these proposals will be seriously considered for very high priority in the department’s spending bid.
To conclude, we have an excellent plan for providing face-to-face CBT—obviously, computerised CBT will be there as well—to all adults who need it, but it still needs to be refinanced for the second half. We need to do something similar for children. I have every hope that the Government will do this because they have shown their willingness to bite this bullet which had been neglected for so many decades. This Government have been outstanding so far in their approach to this, after decades of neglect. I really hope that they will complete the job.
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