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I am less happy about something that I think we will return to, which is how people who already fall through the gaps in care and access to primary care will be treated and whether their situation will be worse. That is because right from the outset I said that what we had to do was apply what is in this Bill to patients and conditions to see how it works for them. In Kingston at the moment, for example, a GP practice has been able to deregister 48 people with mental illnesses who live in a home. They have been scattered among GPs throughout the area. I think that that is very unsatisfactory and there does not seem to be any way of challenging the decision. It worries me that if we are establishing clinical commissioning groups that will have even more independence to take those kinds of decisions, things will get worse for those who need primary care rather than better.

I will not press any of the amendments tabled in my name, but we will return to this issue. I beg leave to withdraw the amendment.

Amendment 9 withdrawn.

Amendments 10 to 11A not moved.

Amendment 11

Moved by Baroness Hollins

11: Clause 2, page 2, line 15, after "of" insert "physical and mental"

Baroness Hollins: My Lords, in moving this amendment I shall speak also to Amendments 105 and 180. I am pleased that they are supported by my noble friends Lord Patel and Lord Alderdice, and the noble Lord, Lord Patel of Bradford. The amendments concern the duty of the Secretary of State set out in Clause 2, in Clause 20 in respect of the National Health Service Commissioning Board, and in Clause 23 in respect of the responsibility of clinical commissioning groups. I speak as a psychiatrist and as a former president of the Royal College of Psychiatrists.

It is time for a paradigm shift in the way we think about the health of the people of this country. When the word "illness" is mentioned, I suspect that in most people's minds there are images of physical illnesses such as heart disease, stroke, kidney failure and so on. The current wording in the Bill places a duty on the Secretary of State, the NHS Commissioning Board and clinical commissioning groups to promote comprehensive services

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in respect of both the physical and the mental health of the people of England. The Bill makes no specific mention of mental illness in respect of their duty as regards the improvement of the quality of services. I suggest that the word "illness" should be changed to "physical and mental illness" so that there can be no question about the Government's commitment to ensure parity between services for physical illness and services for mental illness. The amendments would also be in keeping with the Government's mental health strategy, No Health Without Mental Health, which states:

"We are clear that we expect parity of esteem between mental and physical health services".

Noble Lords might think that there are some pros and cons to these amendments. I have discussed their purposes with mental health charities, service users, practising psychiatrists and other noble Lords. I believe that the pros strongly outweigh any possible cons, but I will deal with the suggested cons first. It has been suggested that there is no need to emphasise that illness encompasses both mental and physical aspects because of course it does; it is so obvious that emphasis is unnecessary. But the stigma associated with mental illness is still such that, on the whole, people do not self-disclose when they have a mental illness in the same way that they might talk about diabetes or cancer. I am sure that noble Lords can remember a time when cancer was a taboo subject, largely because of fear and ignorance. Unfortunately, a lot of the manifestations of mental health problems still evoke fear in the minds of the public. Until we start to name mental health and mental illness much more explicitly, I believe that we will allow mental illness to remain something which is not discussed in polite company, something that is kept out of sight and out of mind in spite of the fact that in each of our lifetimes, one in four of us will have mental health problems. Probably everyone in this House has someone in their family or among their friends or colleagues who is experiencing the symptoms of mental illness at this time.

It is not the same as including children or older people in the definition; nor to including a discrete group of conditions. Mental illness is relevant to every age and social group in the community. We all of us experience either good or less good mental health, just as we all experience good or less good physical health. Our physical health varies according to the presence of specific disorders, as does our mental health, and this applies just as much to children as it does to adults. Imagine a child with a complex neurological disorder who also has a mental illness. The child needs to be treated as a whole person with co-ordinated care by people who understand that the child's mental and physical illnesses have equal priority.

The second possible con is that in labelling mental health in this way, specifically mentioning mental and physical illness, we might exacerbate the split between the two. Perhaps in 100 years' time we will have adopted a sufficiently sophisticated understanding of health that defining health and illness as being about both physical and mental aspects will no longer be necessary. However, at this point in time, clarity is more important than any disadvantage that may come from naming both.



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Another comment has been that mental illness is simply just another condition, similar to diabetes or stroke, perhaps, but this is not a 21st-century way of thinking about mental illness and mental health. The Government very helpfully earlier this year published their mental health strategy and called it No Health Without Mental Health. That is the point of these amendments: there is no health without mental health and there is no public health without mental health.

Given the scale of the changes the Bill introduces, the financial climate within which they will be implemented and the current underfunding of mental health services and care, I am keen to ensure that the Bill enshrines such a principle in law so that commissioning bodies can be under no illusion that they have an equal responsibility to commission high-quality and continuously improving mental health services as they have for services for physical illnesses. It would be extremely regrettable if the importance of mental health commissioning was overlooked because adequate reference to the parity that mental illness should enjoy with physical illness was omitted from the text of the Bill.

Mental health is part of the continuum of health, both for individuals and populations, and it cannot be thought about as if it was a discrete disorder or set of disorders. Medical science today is demonstrating what it should have taught us many generations ago: that physical and mental illnesses are inextricably linked. Do not misunderstand me: I am not suggesting that mental health problems are all down to biology and genetics; environment and relationships play an enormous part in supporting our mental health. This point was made very well on the "Today" programme yesterday, when a service user, a patient who had lived with schizophrenia, spoke about his experience of his illness. Professor Robin Murray from the Institute of Psychiatry, spoke about genetic imaging and other research into schizophrenia which so clearly shows that it is a brain illness, albeit strongly influenced by social and environmental factors.

The mind/body split has unhelpfully been set in concrete within the NHS, which uses different NHS trusts to treat mental and physical illnesses. This unfortunately fails to recognise the fact that depression, for example, is a very common co-morbid condition associated with diabetes, stroke and heart disease. It is not surprising, really, given that the brain is just one organ among many.

Mental illness in someone with a recognised physical illness is often overlooked, delaying that person's physical recovery. As noble Lords will be aware, people who have severe mental illnesses are at an increased risk from a range of physical illnesses, as well as greater levels of obesity, and they have a shorter life expectancy. This is in part because, just as mental illness in those with physical illness is overlooked, so is physical illness overlooked in people with mental illness. We need to do more in all health services, including public health, to ensure that the connections between mental and physical illnesses are better understood; that service responses are co-ordinated; and that diagnostic overshadowing of one by the other is avoided.



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We also need to recognise the part that education, training and research will play in achieving parity of esteem for mental and physical illness. Many factors contribute to the poor physical health of people with mental illness and, for many people with severe mental illness, social stigma, poverty, limited housing options and reduced social networks contribute to the problem, as do difficulties in accessing physical healthcare. I hope noble Lords will support me in inviting the Minister to agree to these small but significant additions to the Bill about which I feel so strongly. I beg to move.

6.15 pm

Lord Patel: My Lords, my name is on the amendment and I am pleased to support it. Before I say what I wish to say, I declare an interest as an honorary fellow of the Royal College of Psychiatrists, an honour bestowed on me by the noble Baroness, Lady Hollins, when she was the president of that college, having been introduced in glowing terms to her by the noble Lord, Lord Alderdice-exaggerated glowing terms, I may add.

Noble Lords may wonder why I received that honour-and so do I-but I remember that at the time I was for several years chairman of the Clinical Standards Board for Scotland. It was during that time that I recognised that the provision of services for mental health was quite appalling compared to the services for physical health. It was through writing of standards for illnesses such as schizophrenia, to which the noble Baroness referred, that I discovered how appalling the situation was, not only in the environment where the care was delivered but in the care itself, and how that led not only to limitations in care but to limitations in resources for research and other end-producing standards.

It was of interest to read:

"Everything in my portfolio straddles the interface between health and care-mental health, social care, long-term conditions, cancer. Take for example mental health. The interdependencies between good mental health and good physical health are clear. Mental health sits at the point where health, social care and public health intersect. Delivering better outcomes in physical health will require mental health to be given parity of esteem. So that both mental and physical health problems get equal recognition in the commissioning and delivery of health and social care".

These are not my words but the words of Mr Paul Burstow, the Minister of State for Health.

"Parity of esteem" is not defined in the document. However, it would be reasonable to expect that this would mean recognition of the equal importance of mental and physical health. Perhaps the Minister will help us with a definition so that we clearly understand what is meant by parity of esteem. You would expect this recognition to be evident in terms of access to mental health services; funding for services proportionate to the disease burden; and mental health being equally at the forefront of the minds of the new clinical commissioning groups and structures.

Sadly, however, this is not the case. For example, for a young person with a physical health problem such as diabetes, to which the noble Baroness referred, who is nearing an age where he is about to start receiving his care in an adult service setting, none of us would expect there to be any problem or difficulty with this move. However, consider a young person with a mental

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health problem about to make the transition to adult mental health services. Recent research indicates that as many as a third of all the young people who arguably needed continuing care did not make this transition. These young people fall into a gap that would not be acceptable in physical health care. Furthermore, even where a service is available, only 5 per cent of young people experience an ideal transition.

Next, consider the disease burden that is attributable to mental illness. Mental illness is a cause of suffering, economic loss and social problems. It accounts for over 15 per cent of the disease burden in developed countries-more than that caused by all cancers. In the UK, at least 16.5 million people experience mental illness. Despite this burden, a proportionate allocation of funding to mental health services often does not reflect that personal and economic scale. Nationally, some 12 per cent of the total NHS budget is allocated to mental health. While it is difficult to call for increased expenditure in the current economic climate, there is clearly a need.

There are clear benefits from mental health being regarded as the same as physical health. For example, poor mental health is associated with the increase of diseases such as cardiovascular disease, cancer and diabetes, while good mental health is known to be a protective factor. Poor physical health also increases the risk of people developing mental health problems.

The amendments are therefore appropriate. They will ensure that the Bill enshrines the principle of equality of physical and mental health in law so that commissioning bodies know their responsibility to commission high-quality and continuously improving mental health services, as they do for physical health. That commissioning bodies have such a responsibility can in no way be assumed from the present wording of the Bill. While it places a duty on the Secretary of State, the NHS Commissioning Board and the clinical commissioning groups to promote comprehensive health services in respect of both the physical and mental health of the people of England, the Bill makes no specific mention of mental illness with respect to their duty to the improvement in quality of services. It refers simply to the prevention, diagnosis or treatment of illness. I support these amendments and hope that other noble Lords will do the same.

Lord Patel of Bradford: My Lords, in speaking in support of these amendments I declare that I was formerly the chair of the Mental Health Act Commission. I have a long-standing interest in working to promote better mental health and in particular how we can best improve quality and outcomes in services. I echo what the noble Baroness, Lady Hollins, and the noble Lord, Lord Patel, have said and shall try to put a little bit more flesh on the bones.

It is clear to me from my work over the years in this area that we cannot and should not try to separate physical and mental illness. The separation of mind and body has been the focus of philosophical debate for many years but it is obvious to anyone who has at some time been unwell that physical problems have a profound impact on our mental well-being and that

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being unwell from a mental illness has profound impacts on our physical well-being. To quote the great American author and thinker, Henry David Thoreau:

"Good for the body is the work of the body, good for the soul the work of the soul, and good for either the work of the other".

I could cite a great many examples that demonstrate that truth. As the noble Lord, Lord Patel, said, compared with the general population, people with depression are twice as likely to develop type 2 diabetes, three times more likely to have a stroke and five times more likely to have a myocardial infarction. Approximately 10 per cent of people have serious depression, but this rises among those with cerebrovascular disease, where rates of major depression are twofold. Among those with diabetes or cancer it rises to threefold, and among those with recurrent epilepsy it can be as high as a fivefold increase. In fact, living with a physical illness can adversely affect our relationships, causing isolation and anxiety, which can be just as debilitating as the physical illness itself.

Apart from the obvious common sense of these amendments, I am keen to see them passed because there is a need to bring these issues to the fore. Mental illness has for far too long been perceived as a Cinderella service lacking the serious attention it needs as part of a fully integrated health service. By creating parity between these twin aspects of our well-being and health, we can ensure that the improvements in quality that we all want to see are realised that much more effectively. In fact, I would go as far as to say that this is one of the single most effective things we could do to bring about these improvements.

By emphasising parity in health and mental illness for the Secretary of State, the clinical commissioning groups and the NHS Commissioning Board, we will see some very tangible benefits. For example, we could see a broadening of the Government's health inequality agenda so that their indicators of disadvantage include mental illness and learning disability. The Royal College of Psychiatrists and the Disability Rights Commission have called for that. That would also help ensure that clinical commissioning groups seek improvements in health through the inclusion of mental illness in the annual health checks undertaken by GPs.

The implications for improvement in commissioning are profound and speak directly to the stated aims of the Bill: that is, continuous improvements in health and in the quality of services. While it is correct that the Bill calls on the NHS Commissioning Board and clinical commissioning groups to promote a comprehensive health service with,

there is still a need to be absolutely clear about the need for parity of esteem in physical and mental illness. This is not clear from the Bill as it stands. As the noble Lord, Lord Patel, said, it simply refers to,

That is likely to perpetuate the current imbalances which exist with respect to mental illness services and needs. For example, we currently spend approximately 12 per cent of health and social care expenditure on mental health services. The actual burden of disease is as high as 20 per cent when taking account of all disability adjusted life years. Bear in mind also that

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there will be only one secondary care specialist on the clinical commissioning group boards, who in all probability will be a representative from the physical health services. This amendment does not mean that there should also be a representative from mental health services but it will ensure that the clinical commissioning group is absolutely clear that it must commission equally high- quality and continuously improving mental health services.

By ending the unhelpful dualism between mental and physical health that has so characterised our services, we will see a holistic approach to health and healthcare. At the same time we will start to end the stigma that so many people have lived with and that has been the cause of so much misery and lost opportunities to help people be well. I am sure all noble Lords will agree that the stigma attached to mental illness has caused service users and their families a great deal of harm. I am pleased to say that public attitudes to this have been changing. In the 2011 Attitudes to Mental Illness survey, the percentage of people agreeing that,

increased from 71 per cent in 1994 to 77 per cent this year. We should continue to support this positive trend in attitudes by emphasising the parity across mental and physical illness as these amendments seek to do.

The statistics show that this is not just a technical or even a semantic issue. The potential benefits are profound. In the same attitude survey, we learn that only 50 per cent of people would feel comfortable talking to their employer about mental illness and nearly a third said they would not be comfortable talking to a close family member or friend. The trends are moving in a positive direction compared to previous years but I am sure noble Lords will agree that we still need to do a great deal more to ensure that people are able to access help quickly and appropriately. Parity between physical and mental illness is one way in which we can strengthen that process.

I know that the Minister is a great supporter of issues related to mental health. I hope that he will support these vital amendments.

6.30 pm

Lord Alderdice: My Lords, I am grateful to the noble Baroness, Lady Hollins, and the noble Lord, Lord Patel of Bradford, for bringing these amendments forward. I have been happy to put my name to them-and I thank the noble Baroness, Lady Finlay of Llandaff, who very graciously withdrew her name in order that I could show my support for the amendments.

Like the noble Baroness, Lady Hollins, I am a fellow of the Royal College of Psychiatrists, albeit I am a recently retired psychiatrist. I would like to support these amendments, but coming from a slightly different perspective from some other noble Lords. When I came into psychiatry many moons ago, we learnt that some 50 per cent of all hospital beds in my part of the United Kingdom were mental hospital beds. That is no longer the case, because there has been a great move towards community care-or at least having people with mental illness in the community, which is not always the same thing. It has many

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advantages, but one disadvantage is that people have lost a sense of the size and severity of the problem. They tend to think of mental illness as a bit like cancer or diabetes, or something of that kind-as another disorder, along with all the rest. But it is not; it is something quite different.

Whenever any of us suffers from a physical illness, it feels like something that has happened to us that we have to respond and react to. But when something happens by way of a mental illness, what is attacked is our very selves, because having mentation is what it is to be a sentient, conscious, reflective human being. I am not talking about people feeling a bit down or depressed or reacting to circumstances or difficulties; I am talking about mental illness. Those differences have sometimes been misunderstood and forgotten, including by psychiatrists in recent years. What disappears, what is attacked and what is under pressure is the very thing that makes you a human being.

One case in which that is most commonly seen is dementia. When my grandfather died and I was consoling my mother, she said, "John, my father died two or three years ago. It was only the shell that passed away yesterday". In truth, the person is gone. That does not mean that we do not care for the rest, but the person has gone. Whether it is an organic disorder, or an organic-related disorder like dementia, or a psychotic disorder such as progressive schizophrenia, or even a neurotic disorder such as obsessive compulsive disorders and anxiety states, it attacks what it is to be a human being. It is a very different thing. All sorts of aspects of the being are attacked-the volition, the will, the capacity to want to do things, disappears. The capacity to care for the rest of the self is often attacked. This means that the very kind of service that you have to provide for people with serious mental illnesses is quite different. Whereas it might be legitimate to say of many physical illnesses that we expect the person to come along and to understand that they have to make a bit of an effort, with someone who has a serious mental illness, whose very capacity to understand and to care for themselves and address those kinds of things, they are attacked by the illness itself, and that expectation must be modified and be quite a different thing.

That leads me to be very supportive of the notion in the noble Baroness's amendment, which I share with her, that in the health service we need to understand the differences as well as the similarities and crossovers between mental and physical illness. Noble Lords have said that they have some optimism that the stigma is less of an issue now than it used to be, and they hope that we might get to a point where it will disappear. I am somewhat of a sceptic about that, because I think that there is something fundamentally different about having a physical illness, when you can feel the lump or the bump and reassure yourself, and mental illness, when frankly at times all of us have some uncertainty about our own stability in that regard-and with good reason. It provokes a very understandable anxiety about the very existence of the self, which means that there will always be a degree of fear about it that does not necessarily exist in physical disorders. I am always encouraged when people become more understanding,

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of course, and I am always encouraged by opinion polls that say that that is the case, but I retain a little uncertainty that we are really there.

When I was training I used to come over from Belfast to the Royal Free Hospital in London for supervision every month. Sometimes the consultant was not ready to see me, so I would sit down among the patients in the clinic. I remember when the consultant came out one day and said, "I've decided that you're really quite stable, John". I said, "I'm sorry, what do you mean-why on earth have you decided that?". He said, "You don't seem to have any anxiety about sitting among the patients in the psychiatric clinic". The truth is that many of us have those kinds of anxieties. It is a different thing.

When it comes to service provision, there is a greater tendency to ignore, forget and set aside the need for the resources for people who are suffering with mental illnesses. One of my concerns, as we move into a time of increasing austerity-and I suspect that will be the case for quite a period of time-is that there will be a temptation to focus on those services where patients can be demanding, emphasise their needs and promote the requirements that they have. Those who suffer from mental illnesses will find themselves shying away and not necessarily having the provision for it. Therefore, to put on the face of the Bill that the responsibility is for people with mental illness and physical illness is an important preventive factor for the next number of years-we can easily judge them to be years-of financial and economic pressure.

It is not just that kind of pressure that exists. Over the last number of years, I have noticed with many of my colleagues in psychiatry that there has been a tendency to slip back towards the provision of care for those who have psychotic illnesses or organic mental states and to try to forget about those with neurotic disorders who may sometimes be dismissed as the walking wounded. They are severe debilitating disorders that destroy lives and damage families and relationships, but many do not get the attention now that they should. Putting it on the face of the Bill would help to keep it in people's minds.

We are not necessarily talking about disturbances of personality. It is a different kind of a matter. I hope that when the Minister comes to reply he will understand that this is not merely a question of the needs of a particular section of the community or a particular disorder or group of professionals. It is about a particular aspect of being a human being, which affects all of us, inside and outside this House, and is extremely important for our health service to recognise and have always brought to its recognition-whether through the Secretary of State, referred to through Amendment 11, or the National Health Service Commissioning Board, referred to through Amendment 106, or at the level of a clinical commissioning group, referred to through Amendment 180. The issue is not with the precise amendments but the precise problem, which I hope that my noble friend the Minister will be able to reassure us upon.

Baroness Whitaker: We have heard very powerful arguments from all sides of the House in support of these amendments, from deep and distinguished

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professional expertise, which in turn is backed by the professional institutions. I know the Minister will want to pay heed to that.

I would like to offer a lay view. These amendments would redress a deep imbalance. The Minister may well say again, as he did in his letter to Peers who spoke at Second Reading, that the Government's good mental health strategy,

And so it does. But that is not the same as making it happen.

The Minister may point out again,

The trouble is that however enlightened the intentions in the strategy, and whatever parliamentary draftsmen may say, we live in a culture which has for centuries relegated mental illness to the realm of the weird, the unmeasurable and the stigmatised, as others have said. Even after the great advances of the last 150 years, neither the resources applied nor that general public understanding which supports political action is remotely adequate for a realistic approach.

What I have seen is that bouts of mental illness severely erode the ability to cope with the problems that life throws up. They do not mean that the sufferer has to be treated like a being apart but they crucially impair the ability to earn a living. How many of those with chronic mental illness hold down a job? They can irreparably destroy relationships, which I heard a lot about when I was on the board of the Tavistock and Portman NHS Foundation Trust, and as a consequence of this combination the sufferer often loses their home. This is devastating; it is arguably more serious than many physical illnesses in its consequences.

When I used to volunteer for Crisis at Christmas, probably over half the homeless people I met were mentally ill. Dedicated professional volunteers came and attended to their coughs and colds, their teeth and their toenails. They sewed their buttons on and gave the heroin addicts methadone but there was never even the most limited talking therapy. I have had colleagues who have kept their proneness to clinical depression secret, even when medication controlled it perfectly adequately, out of fear for the career consequences, and others whose alcoholism was treated as only a disciplinary matter-contrast that with diabetes or severe allergies. This damaging general culture can be changed only if there are enough professional resources to make an impact on it and if there is no excuse, by means of the words-or lack of them-in the statute, to treat mental illness less seriously than physical illness.

How is it that, in answer to the Question which my noble friend Lady Thornton asked on 3 October, the Minister was able to say that the Churchill Medical Centre, a GP practice, deregistered 48 patients with dementia and mental disabilities,

Are patients deregistered because they have asthma or congestive heart disease? I think not. Osteoporosis

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units are funded-good-but local psychotherapy units, which so often have to deal with the residue left by more superficial, short-term and cheaper treatments, are not. Cognitive behaviour therapy, excellent for some purposes, is so widely offered exclusively that it tends to push out a range of other treatments. This does not happen in cardiology. Counselling is often the initial treatment of choice; cheap and with a lesser degree of qualification required.

I heard recently of a single mother, abused and abandoned by her partner, a drug addict, who was not really managing to cope with bringing up small children. She would have had a few weeks of counselling in her GP's practice and medication, followed by brief interventions by clinical psychologists but, like many others, this did not shift either her depression or her behaviour. Her anxiety was too deeply entrenched for short-term counselling to make much difference or prevent her taking her negative feelings and distress out on her children. In fact, she was one of the lucky few. She had a small, local psychotherapy unit near her and she received huge support from her weekly meetings over a long period but that unit, the Camden psychotherapy unit, will shortly lose its funding.

The trend for the full range of mental health treatments to be available only to the rich, or those who can wait a year or more, will be exacerbated if there is not parity of esteem between mental and physical illness. Noble Lords may not be aware that the treatment they or their family might expect is simply not available to more than a very few poor people. It must be emphasised again what is at risk when people's mental health is jeopardised. It is not only their happiness; it is their job, their relationships, their capacity to be effective parents, their resistance to drugs, alcohol and crime, and their home. It is of course also our economy, our well-being and our ease and peace of mind which are impaired. Explicit parity of esteem is essential to redress this cruel imbalance. These amendments serve that purpose. I urge the Minister to accept them.

6.45 pm

Lord Ribeiro: My Lords, I am very pleased to-I am sorry; I know how difficult it is for my noble friend. Would he like to go ahead?

Lord Newton of Braintree: I am sorry but I am really quite slow in standing up, as noble Lords will observe.

I do not want to take a huge amount of time. I am not a member of the Alderdice-Patel-Hollins club and I will therefore not attempt to go down their professional path. I am, however, for the moment at least, a member of another club in that I chair a mental health trust-the Suffolk Mental Health Partnership NHS Trust-so I have an interest to declare. I want to express my strong general support for the basic thrust of these amendments, whatever the wording: to emphasise, in the words of the Government's White Paper, "No health without mental health". We need to ensure that mental illness is treated with parity in these matters, so far as we can.

I will make only another couple of observations. First, it is worth remembering that one of the notorious pressures on A&E departments at the moment is

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people turning up with mental illness problems, in effect, and needing the attention of mental illness specialists. This spills over and crosses the boundaries. I still think it right that there should be separate mental health trusts, but we need to recognise these linkages. Secondly, we need to recognise that this is an area in which integration with social services is particularly important. Integration is key because of the extent to which mental illness services are provided not in hospital but in the community and on a combined operation. As an aside which we will return to, the CQC needs to improve its act in terms of assessing community services for the mentally ill, which in my view it is not at present sufficiently equipped to do. That is a point we shall come back to. My main point is strong support for the principal thrust of these amendments, which I hope my noble friend will feel able to accede to.

Lord Williamson of Horton: My Lords, briefly but warmly, I support Amendment 11, which seems to me to be desirably explicit and logical in the structure of the opening clauses of the Bill. It is desirably explicit because, while I am sure that the Minister actually wants continuous improvement in the quality of service in connection with the prevention, diagnosis or treatment of physical and mental health, those words do not appear in Clause 2. There remains in the wider public some feeling that mental health has a lower priority than physical health. I believe that there has been a huge improvement in the priority given to mental health-I have a lot of experience of that because of my family circumstances-but the feeling I have referred to exists. Therefore, to be explicit on mental health in this clause is good.

The amendment is logical in the Bill because under subsection (1) of the new clause in Clause 1:

"The Secretary of State must continue",

to promote,

yet we do not have that phrase in Clause 2, where we come on to,

That directly contributes to what is expressed in Clause 1, so we need to carry over that phrase and avoid its omission in Clause 2. That is why I support this amendment.

Lord Ribeiro: My Lords, I will be brief on this. I strongly support the amendment because it is important to recognise that mental health and acute clinical health go hand in hand. Most hospitals throughout the country started with psychiatric services outwith the main hospital buildings. Over many years we have tried desperately to integrate the service. We no longer have the concept of the psychiatric Bedlam that was the case in the past.

For the last five years or so of my clinical practice, a rotation of junior doctors came to work for me. They would spend four months on general medicine, four months on surgery and four months on psychiatry. As a consequence, I learnt quite a bit about psychiatry, although I am not sure that they learnt an awful lot

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about surgery. That was an example of integrated care. The importance of it is that a lot of the acute psychotic and suicidal admissions to hospital come through the accident and emergency department. They do not come through the separate door of a psychiatric unit at the other end of the hospital or in a different block. They come to the acute part of the hospital.

I am not saying that the Bill team necessarily overlooked this but, as has been pointed out by the noble Lord, Lord Williamson, if proposed new subsection (1)(a) is to refer to the Secretary of State's duty to and responsibility for "physical and mental health", it stands to reason that, as is currently the case, the Secretary of State delegates responsibility for the provision of the health service to the strategic health authorities and PCTs. Their successor bodies will be the national Commissioning Board and the clinical commissioning groups, so it stands to reason that those two bodies must also have responsibility for mental and physical health. It is vital that the three major groups who have responsibility for the health service in this country-the Secretary of State, the NHS Commissioning Board and the clinical commissioning groups-should all have a responsibility to deal with these two areas of healthcare, because they form part of an integrated service.

Lord Layard: My Lords, some years ago I had a meeting with a newly appointed Secretary of State for Health, although he was not that newly appointed-he had been there for three weeks. At the end of our conversation about mental health, he said, "You know, I've just realised something. I've been in this job for three weeks, I've had about 50 meetings and this is the first time I've heard the words 'mental health'". That says it all. That is how our health service is run and, unfortunately, how the priorities are set. I should just like to review four key facts to show why this is not at all satisfactory.

First, according to the official survey, one in six adults suffers from mental illness, mainly clinical depression or crippling anxiety disorders. These are serious conditions, as has been said. For example, a very good WHO study compared the debilitating effect of depression with that of angina, arthritis, asthma and diabetes. Depression is at least 50 per cent more debilitating than those conditions. That is why half of all the disabled people of working age in our country are disabled by mental illness. It is not a small segment but a massive chunk. It is the largest illness among people of working age.

However, coming to my second point, only a quarter of those who are mentally ill are in treatment, compared with more than 80 per cent of those with the kind of physical illnesses that I mentioned. Last year the chairman of the Royal College of General Practitioners wrote to his members with the question: if you have a patient who needs psychological treatment, can you get it normally, sometimes or rarely? Only 15 per cent said "normally". That is the situation that we are in, which is shocking. The treatments that are available are good. They are recommended by NICE but simply not delivered on a proper scale, even though they are meant to be delivered according to the NICE guidelines.



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Thirdly, what is even more extraordinary is that these are cheap treatments. It is quite easy to show from the experience of the Improving Access to Psychological Therapy programme, for example, that they completely pay for themselves through savings on out-of-work benefits, lost taxes, unnecessary visits to the GP and unnecessary references to secondary care. However, if we ask what commissioners' priorities are, these treatments are of lower priority than many of those for physical conditions that are often much less disabling.

Finally, what is so extraordinary about this, as other speakers have said, is that the problems of people with mental health difficulties also rebound on their physical condition. We also know that many physical conditions rebound on mental conditions. Many physically ill people-those suffering from angina, lung disease or a stroke, for example-suffer from depression. Several proper clinical trials show that, with proper psychological treatment of these mental conditions, the physical condition will improve to the extent that all the money is, again, repaid in savings in physical care. Therefore, we should give much more priority to these conditions.

We also see cases where people are referred with physical conditions that have no physical explanation. Something like half of all referrals to the secondary sector fall into that category of medically unexplained symptoms. Again, many of those will respond to psychological treatments.

Despite all this, we all know where mental health stands in the priorities of commissioners. It counts if there is a serious risk of homicide or suicide. Then they really get to it. However, if not, it is, unfortunately, the easiest area to cut, which is happening on quite a scale at the moment. Two years ago the regulator, Monitor, recorded the fact that mental health services are cut by more than physical health services whenever there is a shortage of money. Monitor recorded this in its advice to trusts on how to budget in the future; it was part of its guidance. It is invariably the case that mental health is cut more than physical health when there is a shortage of money. It is just extraordinary. That guidance was eventually recanted but it is the reflex throughout the commissioning world. I am making the point that this is not only important but a very big thing. That is why it is important that we include the phrase "physical and mental illness", and do so from the beginning of the Bill. If we do not, people will tend to forget mental health, as the department did for three weeks when it was briefing the then Secretary of State. I urge the noble Earl to take this amendment very seriously.

Baroness Murphy: My Lords, I rise briefly to support the eloquent speech by my noble friend Lady Hollins and other noble Lords who have spoken in this debate, if only to give the House a hat trick from the psychiatrists who are here today.

In 1845 the Lunacy Act first separated physical and mental health with the building of the asylums. Before that, in the Poor Law Commission's provision of service to the general population, around 30 per cent of the medical time of general practitioners and specialists who were engaged by the Poor Law Commission was

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spent on people with mental health problems and what we would call learning disabilities. That division, however good it was in developing the services in other ways, has led to a separating out which continued after 1948, to the detriment of the development of services.

This Government and their predecessor have done an enormous amount to right that imbalance. As I have pursued my career in psychiatry, I have seen a dramatic difference in the investment that has been made in mental health services. However, there is still a lack of parity and when people talk about illness they still mean physical illness. I do not know whether the wording "physical and mental" is quite right in this amendment. However, it seems to me that the time is right to have an explicit provision on the face of the Bill regarding the equal importance of mental health and physical health in building a healthy nation. Unless we address physical and mental health together, we will not improve public health. It would be a good time to get such a provision in this Bill as it moves forward with a new style of NHS. I hope the Minister agrees that this is too important a matter to let it go.

7 pm

The Archbishop of York: My Lords, I speak as somebody who supports Mind and as somebody with a brother I followed who had acute mental illness and died from it two years ago. I have listened to noble Lords' speeches, and that of the noble Baroness who moved the amendment, on this amendment and the consequential Amendments 105 and 180. I agree with everything that they have said. It is important to highlight the fact that health and illness include both mental and physical aspects; to me that is not problematic. However, the question I want to ask is, do we still need to speak of them in almost separate categories? The noble Baroness, Lady Murphy, referred to my anxiety; namely, that because we have separated out mental and physical illness, would inserting the words "physical and mental" in relation to illness continue to exacerbate the problem? Is it necessary to put "physical and mental" in this part of the Bill, or will the noble Earl tell us where that matter can be spelt out elsewhere, not necessarily in the Bill?

Noble Lords will probably say of my next point, "We would expect him to say that". I am one of those who believe that human beings are psychosomatic spiritual entities. The element of the spiritual well-being of people is not on the face of the Bill but I am absolutely convinced that, as it stands, my needs would be taken care of because it talks about,

Illness can be physical or mental but it can also be spiritual. I will not detain noble Lords long but when I first became a vicar of a parish in south London I was invited into a home because somebody said that there was a presence there. I did not understand that phrase but I went into the home where there was a young girl who had not been able to move for nearly three weeks. The GP, a psychiatrist and a psychologist had visited the house. Sometimes the girl shouted a lot in the middle of the night. I went into the house and asked how the girl had got into that difficult state. Somebody said that they had been to a witches' coven that night where a goat had been sacrificed and the young girl

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was absolutely petrified that she would be sacrificed next. She could not speak apart from shouting. Doctors, psychiatrists and psychologists had attended the girl. All that I could do was to say a prayer in that little house, anoint the girl with oil and light a candle. I left and received a telephone call later to say that the young girl was no longer terrified and had started to speak. That was not mental or physical illness; there was something in her spirit that needed to be set free.

I am content that the Bill covers all those aspects of the human person simply by using the word "illness" and through establishing a well-being and health board, which suggests to me that that board has a responsibility to ensure that physical, mental and spiritual well-being are taken care of. After all, in our schools these days we emphasise not only the personal, but the physical, mental and spiritual dimensions of a person. Hospital chaplains will tell you that the work they do does not address purely a person's physical and mental aspects. I do not want to divide up a human person. Therefore, I believe that the Bill covers people's needs without inserting the words "physical and mental".

Lord Rooker: My Lords, on balance I agree with the most reverend Primate. I speak purely as a lay person but I am very happy to support the noble Baroness, Lady Hollins. I have no medical training. One almost has to declare that as an interest in this debate. However, mental illness can lead to physical illness and massive social exclusion.

I want to share my experience with the House as it is as relevant today as it was at the time to which I refer. Back in 2003, the then Prime Minister and Deputy Prime Minister commissioned the Social Exclusion Unit to carry out work on how we could attack the cycle of deprivation associated with mental illness. The report was published in 2004 with a 27-point action plan. At that time it was a rule of procedure that a couple of Ministers who were not involved in the matter on a departmental basis chaired the steering group that oversaw the work. I was one of the two Ministers. The other was Rosie Winterton, who is now the Labour Chief Whip in the other place. We launched the report at the headquarters of BT. We did that simply because one of the BT occupational medical staff was on one of the relevant overarching boards, but BT's record as an employer in relation to the mental health of their employees was absolutely first class. Therefore, we were happy to use the BT headquarters for the launch.

Two departments later, as I travelled round Whitehall departments, I wondered what had happened to the 27-point action plan. These things are developed but the Ministers and civil servants involved with them move on. The relevant civil servants were very surprised to hear from a Minister who had had such a tenuous connection with the work he was asking about. The noble Baroness opposite is aware of this as she was involved with the Social Exclusion Unit. The civil servants told me that the action plan was still in place. I have not familiarised myself with what has happened to it over the past couple of years and I would like to be given an update on it. I would like to share with noble Lords some of the points contained in the factsheet that the Social Exclusion Unit published as

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they relate to some of the myths that have been mentioned. We need to expose those myths and meet them head on.

Four myths are exposed in the Social Exclusion Unit's factsheet. I will not detain noble Lords for long as this has been a fascinating debate. The first myth is:

"People with mental health problems are dangerous and violent".

However, the factsheet adds:

"People with mental health problems are more likely to be the victims rather than the perpetrators of violence. Less than 5 per cent of people who kill a stranger have symptoms of mental illness".

The second myth states:

"Mental health problems are rare".

We have heard that myth being busted in tonight's debate. Indeed, the factsheet states:

"Common mental health problems affect up to one in six of the general population at any one time. Almost everyone will know someone who has had mental health problems at some point in their lives".

The third myth states:

"People with mental health problems are incapable of work".

However, the factsheet states:

"US research found that up to 58 per cent of adults with severe and enduring mental health problems are able to work with the right support".

I will give an example of that in a moment.

The fourth myth states:

"People with mental health problems do not want to work".

However, the factsheet states:

"35 per cent of people with mental health problems who are economically inactive would like to work, compared to 28 per cent of those with other health conditions. Many successful people have had mental health problems".

In fact, as part of the exercise, I went for a day and a half around London to look at projects manned exclusively by people with mental illnesses. One was at a restaurant, and the only person involved in the restaurant who did not have a mental health problem was the chef, who had come down from a Park Lane hotel to do the training. Everyone else in the kitchen and the front office had a mental health problem. In fact, nine months later, I took my private office staff for their Christmas lunch there. My visit had been in April and I said, "If I am still around at Christmas we will come here for our private office lunch". Indeed, we did that. When visiting the three projects, I was driven around by one of the patients. I have never felt as safe in a van driven by anyone else. I had no problem whatever. The idea that normal activity cannot take place or that you cannot be included socially is, of course, a myth.

I want to share one of the other aspects that we put out in a factsheet on this issue. The factsheet states:

"Nearly one-fifth of respondents to the Social Exclusion Unit's consultation argued that mental health services needed to become more socially focused"-

and more holistic. The factsheet continued:

"GPs issue sickness certificates when they assess that a person cannot perform their usual work. Mental health problems are more likely to be listed on the sickness certificates in the most deprived areas of the country".



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That is another fact that we must take on board.

"It is important to ensure appropriate pathways of care between primary and secondary services; up to 28 per cent of referrals from primary care to specialist services are inappropriate".

I will not read out all the facts, but shall quote the final two. It is stated:

"The range of services is more limited in rural areas, with specialist services often absent".

That is the reality of many services, but this is the one that we are dealing with. It continues:

"In 2002, 87 per cent of rural households were 4km away from a GP surgery".

My final example states:

"A person with schizophrenia can expect, on average, to live for ten years less than someone without a mental health problem, mainly because of physical health problems".

One therefore has to deal with: stigma and discrimination-and we have heard examples of that; the role of healthcare professionals, which we dealt with in the factsheets relating to employment, welfare and benefits; and the role of families and carers, in particular. I shall leave alone the criminal justice system and other issues. Putting the amendments in the Bill is simple-it does not cost anything in terms of money; it should not upset the parliamentary draftsmen; but it sends a massive signal to the whole structure of the National Health Service that Parliament has highlighted and identified this issue, which relates to both Houses. We do not want it to be put in a backwater. We do not want it to be the first thing that is cut. People have to be treated holistically, because we know that if their mental health problems are not treated properly, physical problems start and we then get the queues at accident and emergency-and other pressures on GPs.

I am therefore very happy to support the amendments in the names of noble Lords from all around the Committee. The work of this Government, which I applaud, was mentioned, and I have provided examples of the work of the previous Government where we were trying to deal with the relationship between social exclusion and mental health. It went right across the board-every government department had a role in this. The issue should not be left just to the health department or the National Health Service. It must be dealt with properly by every department-the economic ones as well as the health ones.

7.15 pm

Baroness Armstrong of Hill Top: My Lords, it is particularly apt that I follow the speech of my noble friend because, in supporting these amendments, I wanted to relate a little of my experience as the Social Exclusion Minister who came in and tried to learn from all the other things that we had done in government-and what we had missed and needed to come back to. One of the issues that we came back to that is particularly apposite to the amendments related to people who do not fit into any category, who are the most vulnerable and who turn up at different places to try to get a service. No service treats them as an individual who has several problems.

Most of these people have mental and physical health problems and probably have an addiction. They are probably difficult to deal with and are likely to get

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aggressive because they know that they are not getting the response they need to help them move forward. We set up some pilot projects which I now work with as chair of the Cyrenians in the north-east-a charity which took up one of those pilots and extended it. The pilot is paid for now by Newcastle City Council and the PCT, which is much bigger than the subsequent clinical commissioning groups will be. I was not sure whether I should raise this matter in the previous group of amendments or in this one, but I do not want to keep having to rise to speak because there are issues here that the Government need to address. I chose these amendments because they relate to the Secretary of State, the national Commissioning Board, and the clinical commissioning groups.

Some things will have to cross those boundaries and be paid attention to by more than just a clinical commissioning group on its own, because the people we are talking about do not remain in one place. Sometimes there are insufficient of them in one place for a clinical commissioning group to take account of what they are going to need. We have people who go round and find the most disadvantaged and the most dispossessed-the ones who are not fitting in anywhere. We use ex-clients to go and find them. Most of the money comes from the local authority.

We persuaded the PCT to appoint a community matron with whom we work and to whom we send those people. She is then able to assess their physical and mental health needs. This has substantially reduced in-patient care, and because we have a different system we can show that fewer people end up in A&E and are then admitted to hospital. Such an arrangement can save money but is also able to provide interventions at an earlier stage-and that was what attracted me about the amendments, because they relate to prevention, diagnosis and treatment.

However, we do not work just with the homeless; we also have three projects for addicts. One of them is a 12-step, 12-week day-centre programme. The programme is fairly tough and the addicts have to be abstinent. We pay for that with money from three PCTs which were so enthusiastic about the work and what it was producing that they are now funding another centre for addiction, where we take in on a residential basis mothers and their children to seek to prevent the children going into care-because that was what was happening. We still have a small problem with the acute providers because sometimes when a family was going to come to us the providers had increased the methadone rather than helped the mothers to come off the methadone. We use the recovery method rather than methadone.

I hope that the Committee can see that these are complex cases, with complex interventions that are aimed at preventing more difficult interventions later.

I cannot see one clinical commissioning group commissioning any of this work, because it will be too expensive and there will not be a sufficient body of people to justify the work and money that it would need to put in. That is why, in the new architecture, the Government need to think how they will respond to those more complex problems, where the voluntary sector is coming up with more innovative solutions, but they need also to deal properly with what is often

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called dual diagnosis-I think it is often triple and quadruple diagnosis-where people have more than one problem. We need to bring the different groupings together to make sure that the needs of that individual or that family are addressed in a holistic way. It is important to recognise that more than a physical illness is brought to the table, as it were, in those cases. At least the amendment acknowledges that both physical and mental illness must be addressed.

We will get a complex architecture under the Bill, and it will be all too easy for people to fall back through the cracks within that architecture and for there not to be a holistic approach. The next set of amendments, which talk about integration, are also important, and I will come back to them, but the Government need to think again about how to address those complex issues in a way that allows the whole person in that patient to be addressed in a more effective way than we are often able to do at the moment.

Baroness Masham of Ilton: My Lords, I first want to ask a quick question to my noble friend Lady Hollins or the Minister. Would the words physical and mental include those people who have a drug and/or an alcohol problem? Would addiction come under "mental"? I do not want those people to fall through the net, as was said by the previous speaker.

Lord Mackay of Clashfern: I just wanted to say a word or two about the drafting involved in this. The noble Lord, Lord Williamson, pointed out that the opening clause, which is the foundation of the health service, states:

"The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement ... in the physical and mental health of the people of England, and

(b) in the prevention, diagnosis and treatment of illness".

That is precisely the phrase that is the subject of the amendment, but it comes earlier in the Bill. I cannot believe that when the people who put the health service together in 1946 used that phrase, they did not have in mind that physical and mental health involved the idea that if there was illness, it could be either physical or mental. If we are to change an exactly similar phrase later in the Bill, consideration needs to be given as to whether we should do it at the beginning which is, after all, in many ways the most important place.

I have every sympathy with all that has been said, and I am sure that it is right that we take serious account of it. We must remember the point made by the noble Baroness, Lady Murphy, about the need for integration of treatment for mental illness along with physical illness. Anything that separates them might not be conducive to progress. I have every sympathy with the proposal.

Baroness Thornton: My Lords, I congratulate the noble Baroness, Lady Hollins, on bringing forward the amendments and all those who have spoken in what I think has been an extremely useful debate. All those months ago, we had all-Peers meetings about this and many other issues. I am sure that the quality and comprehensive nature of the amendments owes something not only to talent and expertise but also to the fact

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that the experts in the House have been working with many organisations over a long period. I congratulate everyone on the quality of the debate and the amendments.

The amendments approach the Bill holistically-I do not really like that word. They concern the Secretary of State's responsibilities, the duties of the Commissioning Board and the duties of the clinical commissioning group-the triggers, the levers that may make this a reality. Because of that, I am very attracted to them. It is also important that they express the expectation of parity of esteem between mental and physical health services. As has been said, my Government and this Government have certainly made progress on this issue. I look forward to hearing the Minister's comments, and I hope that he will find some way to recognise the support for the amendments across the House.

Earl Howe: My Lords, I agree with the noble Baroness, Lady Thornton, that this has been a debate of very high quality, covering a topic of huge importance. All the amendments deal with the same matter. Each seeks to amend the duty of quality to include an explicit reference to the prevention, diagnosis or treatment of physical and mental illness. Amendment 11 does so for the Secretary of State; Amendment 105 applies to the NHS Commissioning Board; and Amendment 180 applies to clinical commissioning groups.

I completely share the noble Baroness's concern that we should never forget mental health in the drive for improving quality-quite the contrary. The noble Lord, Lord Patel of Bradford, and many others, mentioned parity of esteem between mental and physical health and the need to end the dualism in thinking that has in the past hindered an holistic approach to care. Noble Lords have expressed the concern that the Bill is wrongly silent in not referring explicitly to mental illness. I hope that I can successfully plead not guilty to that charge. First, I reassure all noble Lords on the central point of drafting, which is that all references to illness already include both mental and physical illness. The term illness is defined in Section 275 of the National Health Service Act 2006 as including mental disorder within the meaning of the Mental Health Act 1983. As a result, references to the prevention, diagnosis and treatment of illness would already apply to both physical and mental illnesses without the need for those additional words. The definition is already there. Therefore, the signal mentioned by the noble Lord, Lord Rooker, is already there.

The new duties placed on the Secretary of State for Health, the NHS Commissioning Board and clinical commissioning groups continuously to improve quality as defined by the noble Lord, Lord Darzi, already apply to the provision of both physical and mental health services. That is not to say-and I would not seek to suggest-that such services need no improvement. The noble Lord, Lord Patel, was quite right to draw attention to variations in mental healthcare around the country, despite the significant additional resources that have been directed to mental health services in recent years.

I fully agree that the National Health Service must look holistically at both the physical and mental needs of the patients whom it is there to serve. That is why

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the NHS outcomes framework, which we published last year, seeks to drive better health outcomes for those with mental illness. That is where the difference will lie in future. For example, Domain 1 of that framework, which focuses on preventing people from dying prematurely, includes a specific indicator on premature mortality in people with serious mental illness. Domain 2 of the framework focuses on enhancing the quality of life for people with long-term conditions, regardless of whether these are physical or mental health-related. However, to guard against the risk that there might be an overriding focus on physical health, there is also a specific indicator looking at the employment of people with mental illness. Clinical experts, including the Royal College of Psychiatrists, agree that this is an important outcome for people with mental illness and one that the NHS can make a significant contribution to improving. Finally, Domain 4 of the framework focuses on:

"Ensuring that people have a positive experience of care",

including a specific indicator to capture the experience of healthcare for people with mental illness.

7.30 pm

In addition to the NHS outcomes framework, there are a number of other policy initiatives, tools and levers to support the improvement of mental health outcomes. The noble Baroness, Lady Hollins, and my noble friend Lord Ribeiro very pertinently mentioned mental health comorbidities, and this is where the work of NICE will have a part to play. We have asked NICE to prepare quality standards on many mental health topics, including depression with chronic physical health problems. The full library of quality standards, which is expected to total around 175, will contain a further large range of mental health topics.

The noble Baroness, Lady Hollins, and my noble friend Lord Newton referred to No Health Without Mental Health, which we published in February. This is a cross-government mental health outcomes strategy for people of all ages. It was co-produced with the mental health sector and public health and social services organisations. It is probably worth my briefly setting out the six overarching objectives in that strategy.

First, more people of all ages and backgrounds will have better well-being and good mental health. Fewer people will develop mental health problems by starting well, developing well, working well, living well and ageing well. Secondly, more people who develop mental health problems will have a good quality of life, with a greater ability to manage their own lives, stronger social relationships, a greater sense of purpose, the skills they need for living and working, improved chances in education, better employment rates, and a suitable and stable place to live.

Thirdly, fewer people with mental health problems will die prematurely, and more people with physical ill health will have better mental health. Fourthly, care and support, wherever it takes place, should offer access to timely, evidence-based interventions and approaches that give people the greatest choice and control over their own lives in the least restrictive environment, and it should ensure that people's human rights are protected.



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Fifthly, people receiving care and support should have confidence that the services they use are of the highest quality and at least as safe as any other public service. Sixthly, and finally, public understanding of mental health will improve and, as a result, negative attitudes and behaviours towards people with mental health problems will decrease.

I believe that those are the right aims but we were also quite clear in the strategy that we attach equal importance to mental and physical health, and that mental health services should have "parity of esteem" with physical health services. We have already made very useful progress in implementing the mental health strategy, and I suggest that this work on the ground is at least as important as having appropriate wording in the Bill.

The noble Lord, Lord Patel, asked what the meaning of "parity of esteem" is taken to be by the Government. We mean that mental health should be a priority alongside equally pressing physical health problems. That is why the strategy is called No Health Without Mental Health and why we have included mental health in the NHS outcomes framework, as I have mentioned, and commissioned half a dozen NICE quality standards on mental health topics, with more on the way.

The noble Lord, Lord Patel of Bradford, made the very good point that clinical commissioning groups will need good advice on mental health issues. We entirely agree but this will come in a variety of forms. The board and clinical commissioning groups will be required to obtain clinical advice from a broad range of professionals with expertise in the prevention, diagnosis or treatment of illness and in the protection or improvement of public health appropriate to enable them effectively to discharge all their functions. This would include, for example, obtaining advice when making commissioning decisions-for instance, for people with specialist mental health needs. There are powers in the Bill to enable the board to issue guidance to CCGs on the discharge of this function.

As well as promoting effective clinical leadership and multi-professional collaboration around specific conditions and pathways, we expect doctors, nurses and other professionals to come together in clinical senates to give expert advice which we anticipate clinical commissioning groups will follow in practice on how to make patient care fit together seamlessly in each area of the country. Clinical senates would provide advice and support on a range of issues and from a variety of health and care perspectives, including those of mental health specialists and of professionals who sometimes go unheard, such as allied health professionals. Health and well-being boards, as we have already discussed, will provide an opportunity to join up health, social care and services that have an impact on health generally.

The most reverend Primate the Archbishop of York asked where would be the right place in the Bill to show the importance of mental health, if not here. While it is important to remember the role of the Bill, it is equally important to bear in mind the role of non-legislative work. I have already referred to some of that. The Bill is designed to set out a framework in

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which high-quality care can be delivered. The Bill and its duties cover all services, making no distinction between mental health and physical health. The wider, non-legislative work offers broader opportunities to delve into the detail required-for example, the NICE quality standards, commissioning guidance and the outcomes framework-and that is the work that will make a real difference to improving the quality of services, fulfilling the duties set out in the Bill.

The noble Lord, Lord Layard, referred in his customarily authoritative way to talking therapies. I completely agree with him that this is a very important issue. He will know that we have committed to invest more than £400 million over the next four years to expand access to psychological treatment-IAPT services-across England. We are building on the previous Government's excellent work in this area, which has seen more than 600,000 people with mild to moderate depression enter treatment. I pay tribute to the noble Lord for all his efforts to shine the spotlight on this important area.

The noble Baroness, Lady Armstrong, challenged me to show how the new NHS would cope with those with multiple and complex needs, and she was right to do that. I completely agree that people need to come together to ensure that service planning is holistic. She is equally right to say that sometimes an individual clinical commissioning group might not have that capacity. However, here again the role of health and well-being boards will be critical, bringing people together, setting out a joint strategy and promoting joint working. I look forward to longer debates on this topic over the coming weeks.

As I mentioned earlier, Section 275 of the National Health Service Act defines the term "illness" to include mental disorder within the meaning of the Mental Health Act. Where it appears in Section 1 and other provisions of the Act, it has always been referred to without those additional words. Instead, the term has always been defined to include mental and physical illness. Therefore, like the noble Baroness, Lady Murphy, and the most reverend Primate, I do not think that it would be desirable to make an express distinction between the two in the provisions of this Bill, particularly when we need the service to think holistically about both the physical and mental health needs of patients.

With those comments, I hope that the noble Baroness, Lady Hollins, is more reassured and will feel able to withdraw her amendment.

Baroness Hollins: My Lords, I thank the noble Earl for his answer and indeed for the sustained interest and commitment that he has always shown to mental health services. I have been heartened by the enormous support across the House for my amendments and was impressed by the breadth of interest shown in mental illness.

There is wide recognition of the need to try to bring mental illness more into view, particularly perhaps to make it more explicit in the Bill. The indicators of better outcomes, about which the Minister spoke, are indeed welcome. We have heard how much they are needed. I hear every day of how mental health services are being disproportionately cut. We are still a long way from the kind of holistic service that we would all

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like to see. That is the difficulty and why I still feel quite strongly that we need to name mental and physical health. This may not be the right place in the Bill to do it, but I still think that when they hear the word "illness", people think about physical illness. It may be defined but I do not think that it is what people hear. I have heard Ministers of Health and Secretaries of State speaking about health and illness over many years and nearly always when they do so we know that everybody is hearing "physical illness" and not hearing or thinking "mental illness". We know that mental illness includes addiction and a wide range of different disorders and conditions.

I take note of what the noble and learned Lord, Lord Mackay of Clashfern, said and his question about where the amendment would best fit. I am willing to withdraw the amendment but I hope to hear more discussion and thought about how to show more explicitly in the Bill that there is a real intention in a 21st century Bill to have parity for mental and physical illness. In 100 years' time somebody could be standing here arguing to take away the words "mental illness" because they are no longer needed, but we are such a long way from being able to do that. I am not arguing that mental illness is just a medical condition-not at all. It is a condition, as the noble Lord, Lord Alderdice, reminded us, which affects the very essence of our being. It requires integrated services and integrated approaches; it requires medical attention. But it also requires an awareness of the social recovery models of support and help. I will bring back the amendment at the next stage. I beg leave to withdraw the amendment.

Amendment 11 withdrawn.

Amendment 11A not moved.

House resumed. Committee to begin again not before 8.43 pm.

Big Society

Question for Short Debate

7.43 pm

Asked By Lord Ponsonby of Shulbrede

Lord Ponsonby of Shulbrede: My Lords, noble Lords will be aware that this year is the 650th anniversary of the establishment of the magistracy. Iwas sworn in as a magistrate nearly six years ago and I now sit both on adult and youth matters. The lay magistracy is a triumph of volunteerism and localism. Even in central London where I sit, most of my colleagues have lifetimes of experience of living and working in London and bring this experience to their adjudications on a daily basis. Like jurors, magistrates are unpaid and unqualified; unlike jurors, however, we will hear hundreds of cases a year and we are trained and advised by experienced legal advisers who keep us on the legal straight and narrow. Some 95 per cent of criminal cases are dealt

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with in the magistrates' courts. I believe that all this adds up to a unique institution which is a cornerstone of civic life.

So what of the future? In this short debate I want to concentrate on areas where I believe the magistracy could play a greater role in enhancing the public's faith in the justice system. There seem to be three main problems affecting the public perception of the court system. The first is the poor administration and slowness of the court system itself. The second is the public scepticism on the appropriateness of community-based sentences and the third is the representativeness of magistrates themselves. To tackle the first issue-the poor administration of the court system itself-when I first sat only six years ago I was amazed at the complete lack of computer support. The whole process in court was paper-based. Now it is common to book trials online, for lawyers and JPs to check sentencing guidelines online and also to call up maps and photos of locations for traffic matters, and things like that. Nevertheless the bulk of the process is still paper-based. I was heartened to note that in the new Westminster court house in Marylebone every desk position in every court has a plug and phone jack to enable a computer to be set up. Digitising the criminal justice system is a huge and complex task but progress is being made and the benefits are there to be reaped. I understand that 2014 is the target date for completing this task.

However, court is a team effort and each member of the team needs to contribute to the effective management of the case load. Digitising the system will reap big benefits but will never replace a properly motivated and appreciated court team. The Government need to keep that at the forefront of their mind when introducing sweeping changes. It has to be a concern that cuts to staff will hold up progress towards digitising the courts process and reduce staff morale, which in turn will affect performance and the public view of the effectiveness of the system. Magistrates can help by setting the tone of the court itself-making sure it is well managed, making progress whenever possible and putting the interests of justice first without cutting corners or delaying decisions. I believe that magistrates can and do help the process by using courtrooms when appropriate and being sympathetic to other people using their computing systems.

The next matter is public scepticism on the appropriateness and effectiveness of community sentences. I believe that this scepticism is exaggerated mainly by the press and that most people want community sentences to be used as much as possible. They also want them to be tough and effective. I read the speech made by the noble Lord, Lord McNally, to the University of Hertfordshire at the beginning of October and I agreed with his aspirations for community punishments. It is, however, in the role of magistrates that we see a lot of people who have reoffended while on community sentences but we do not see those who succeed and never offend again. There are, of course, some limited interactions with people while they are completing their community orders but this tends to be the exception rather than the rule. I would also point out that those who point to the ineffectiveness of short-term prison sentences when compared to community sentences in stopping reoffending

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only tell half the truth. In my experience, the vast majority of those given short-term prison sentences have previously failed on community orders, so to say that short-term prison sentences are ineffective is misleading.

Nevertheless, I welcome the development of community -based sentencing options, such as restorative justice programmes, neighbourhood justice panels, community courts, and other initiatives which I know the Ministry of Justice is pursuing. I believe that these are worth while and worth supporting. The noble Lord, Lord McNally, went into some depth on his aspirations for neighbourhood justice panels and spoke with feeling-I read it with feeling-about the potential benefits of such a system. As far as I can see, the system will be based on the approach now taken with youths and locally recruited youth offender panels. As I said, I share his aspirations but I think that it is fair for me to point out the potential pitfalls of such a system.

I believe that the courts and victims in particular could become separated from the sentencing process itself. At present it is rare for victims to be in court when an offender is sentenced, and it will be even rarer if there is a separate and subsequent neighbourhood justice panel meeting at which the activities of the community sentences are agreed. I accept that this is a conundrum with no easy solution that we also grapple with in youth courts. At its heart is the fact that there needs to be a level of trust and confidence between those who give the sentences and those who administer them: namely, the probation service and youth offender teams. Poorly administered community sentences can and do undermine both magistrates' and victims' faith in the sentence. Breaches in particular need to be brought to court in a timely manner.

I have visited a number of unpaid work projects over the years and have invariably been impressed by them, but sentencers need to be confident that the programmes offered are realistic, achievable and above all properly administered. I will add that I believe that localism is a good aspiration for the courts system. Even in London, most people regard themselves as local to a particular area and would like to see community sentences carried out in their areas.

I move on to the representativeness of magistrates. Magistrates, like jurors, should be drawn from the communities in which they live. It is desirable that they are drawn from all areas, and this is particularly important for areas where there is a high crime rate. Achieving this is difficult and I know that the matter is taken very seriously by the committees responsible for the recruitment of magistrates. Nevertheless, it is a fair generalisation that certain groups are underrepresented on the Bench. I would nominate Afro-Caribbean men as an important and underrepresented group. Having said that, I believe that Benches are quite diverse, but it is perhaps inevitable that those with the time to give to this public service predominate. The Ministry of Justice should play an active role not just in communicating opportunities to serve as a magistrate but more generally in promoting the role of the magistracy itself.

I have two simple suggestions to increase diversity on the Bench. First, adverts for magistrates should be placed on buses and tubes. They used to be, but I have

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not seen an advert for many years, and I have long-standing colleagues who came on to the Bench after seeing those adverts. My second suggestion is that there should be a modest payment to local magistrates. We are not paid at the moment, whereas local councillors, tribunal members and Members of this House are paid. I remember that the justification for starting to pay local councillors was precisely to increase the diversity of those who serve on local councils.

In conclusion, I have spoken about three areas: poor administration of the courts system, public perception of community sentences and the representativeness of magistrates. In each area, magistrates play a crucial role in the development of the courts system. All communities have the right to be confident that their local court services are delivered to a nationally consistent and high standard. It is of paramount importance that members of the public maintain their trust in the courts system and in the thousands of lay magistrates who sit every day to decide on matters that affect their fellow citizens. This debate was framed as a question. It is a genuine one and I look forward to the noble Lord's response.

7.53 pm

Baroness Miller of Hendon: My Lords, as I am the first speaker after the introduction by the noble Lord, Lord Ponsonby, I thank him on behalf of us all for bringing this interesting subject to the House, and for the comprehensive way in which he dealt with it. I first declare an interest; from 1970 to 1993, when I was appointed to the Front Bench of your Lordships' House, I was a magistrate in both adult and juvenile courts. I assure your Lordships that in those 23 years I had my fair share of sleepless nights after some cases, worrying about whether I had done the right thing by certain defendants.

We are all aware of the long history of the magistracy: both the lay magistracy and, since the 19th century, the stipendiary system. By performing duties as lay magistrates, non-lawyers have been one of the earliest examples of the so-called big society for centuries, and I have frequently explained to foreign friends that they are in effect a sort of jury with limited sentencing powers. The lay magistracy has long since ceased to be the province of the local squire, and no longer conjures up a vision of Tory ladies wearing flowery hats, although when I joined the Bench I was told-I ignored the instruction-that I was expected to wear one, with or without decorative flowers.

As the noble Lord, Lord Ponsonby, said, magistrates' courts deal with well over 90 per cent of all criminal cases, as well as a wide range of civil matters. I will confine my remarks to their role in administering the criminal law. It is perhaps not quite good form for me to refer to one of my earlier speeches in your Lordships' House, but my maiden speech some 18 years ago was on the theme of law and order. The point that I made then, which bears repeating, is that the criminal law is there first and foremost to protect the public. It does this by punishing the wrongdoers-I will use the right word: criminals-and thereby acting as a deterrent to them and others from further offending. The possibility of rehabilitation is a very worthy objective, but one which perhaps all too often does not work.



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The recent outcry from the usual libertarian sources that the penalties imposed on the looters, arsonists and rioters last August were too severe was typical of the muddle-headed thinking that pervades some quarters. In arguing for the rights of the hooligans and criminals, they ignored the rights of the people who had their homes, businesses and jobs destroyed, in many cases just for the so-called fun of it-in many cases, it transpired, by people with existing records of criminal activity that had hitherto gone largely unpunished.

The deterrent effect of the recent sentences will last only as long as the short-term memory of the potential perpetrators lasts: not long, I am afraid. What they will remember is that in future they should disguise themselves better from the CCTV cameras that, despite being decried in some quarters as an undesirable Big Brother device, did their job on this occasion.

The police have the power to require people to remove masks. This is not quite adequate. On four occasions I have attempted to persuade political parties on both sides of the aisle to make it an offence to wear a disguise at any public demonstration, just as it is an offence to carry an offensive weapon. To no avail, I am afraid, but I repeat my appeal tonight.

As to softer sentencing for the rioters and looters, I am reminded of the procession of mothers pleading for a light sentence for their child, who may have committed the most despicable offence, by telling the court: "He's a good boy really". Just like some of the recent offenders who to their horror, instead of a slap on the wrist, got a short-and sometimes not so short-sharp shock despite not having any previous convictions.

Community service orders are regrettably inadequately staffed and funded and sometimes consist of futile lamppost-counting operations. Your Lordships may have read in the paper only yesterday of a man who had to be punished with a curfew for persistently failing to turn up for his community service duties on Mondays because he had a hangover as result of spending Sundays drinking in public houses and watching football. Where an unemployed man gets enough money to get drunk in a public house is beyond me.

One problem we face is that things like ASBOs and referral orders, which we used to call probation, are in some cases regarded as a badge of honour. I well remember leaving court one day and a young man whom I had just put on probation was heard telling his friends outside that he had "got off". I will not repeat what he said about the magistrate who was stupid enough to do that. That typical attitude is part of the problem.

The magistracy, both lay and stipendiary, as well as the rest of the judiciary, has a part to play in the big society. It is to ensure that law-abiding citizens who want to give something to society-big or small-can safely and freely go about their daily lives without fear for themselves, their homes, their possessions and their businesses.

8 pm

Lord Patel of Bradford: My Lords, I greatly welcome this timely debate and add my thanks to my noble friend Lord Ponsonby for having secured it. I should declare that I am the honorary president of the Bradford Court Chaplaincy Service, which is, in my opinion, an

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excellent example of a court service involved in the big society, and I shall talk more about this unique service in a few minutes.

This is a very timely debate because, as noble Lords are aware, the Constitution Committee of this House is currently hearing evidence on the judicial appointments process. I understand that there has already been much discussion about the importance of diversity in this process and about how it makes our judiciary not only more representative of the broader population it services but ensures that the integrity and authority of the courts are sustained. This is also a very important issue with respect to the big society.

I am not a great fan of the term "the big society" as I am still far from clear that it actually means what it professes to mean. It sounds like the sort of thing that we are all involved in and suggests a model for society that is based on inclusion, but I do not see many plans for increasing inclusion. In fact, we are in grave danger of seeing a far less inclusive society as we continue to witness the retraction of the voluntary sector and restrictions in access to education. However, let us leave the political divisions aside for now and accept the big society for what it should be: a fair society, based on transparency and accountability in which everyone feels they have a chance and a stake.

On such a definition the role of the magistracy can be seen to be vital. What is the magistracy? Well, most magistrates are, of course, justices of the peace, like my noble friend, who act on a voluntary basis to administer the law in our lower courts, and they do this with the authority of being highly respected members of their communities. Can a single magistrate represent all of the local community? Of course not, and we should not expect them to, but in terms of the big society and inclusion, we should expect the magistracy as a whole to be accessible to all and not limited in how we regard respect.

Just as the big society is remarkably diverse, we need also to see a magistracy as a whole that is diverse. We should be accustomed to seeing more women and people with disabilities, more lesbian, gay, bisexual and transgender magistrates, more black and minority ethnic magistrates as well as those who are younger, older, of all faiths or none, married, single or in a civil partnership and, of course, wealthy or poor.

If it is the administration of justice that we are speaking about, then we should ensure that there is also a justice of administration: a justice that reaches out to those who are excluded and actively brings them into the process and a justice that recognises that no single group can expect to make judgments in the interests of the community if it is not rooted in the community that it presides over. That is the real basis of respect and it is something that must be tangible.

I mentioned that I am fortunate to be the honorary president of the Bradford Court Chaplaincy Service, and I want to end by talking a little about that service because it says a lot to me about the place of a modern court service in the big society. The Bradford Court Chaplaincy Service was established as a charity in 2008 with the aim of providing a multifaith chaplaincy service to all court users, including people of faith or with no faith, irrespective of race, culture, creed, special

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needs or sexual orientation. It is a truly inclusive service working as an integral part of the court and providing vital support, without prejudice, at what is often the most stressful period in someone's life.

The service was founded by a former chair of the Bradford magistrates' Bench, Mary Carroll, together with four of her colleagues on the Bench, working together with local hospital chaplains and community members. This is very important because it was an initiative that really came from the local community, first through the wisdom and foresight of the JPs and secondly through the involvement of other local community members. It was also supported at the time by the then Lord Chancellor, my noble and learned friend Lord Falconer, which shows how much government has a role in supporting the big society. It really is the big society at work. Currently, the service has two part-time chaplains, one Muslim and one Christian, and around 40 volunteers who come from all walks of life in the local communities. They work mainly with defendants, many of whom are unrepresented and often very vulnerable. They also provide a service for all the staff of the court services. They provide 10 sessions in the magistrates' and coroner's court and nine sessions at the Crown Court every week. Last year, the service saw approximately 1,400 people.

The volunteers and the dedication they demonstrate do not just happen; a service like this needs a great deal of support, time and resources. The big society cannot mean that everything is voluntary. Such an approach would not thrive as the court chaplaincy service demonstrates. The volunteers are supported by the part-time chaplains, who provide daily guidance, advice, training, ongoing mentoring and supervision. This ensures that the volunteers can get on to do what they do with confidence and skill and, of course, that confidence in the service provided by having a professional structure passes to those who use the service and those who refer people to it. That to me is the key to a successful big society approach in our magistracy combining the power of volunteers who come directly from the full range of local communities with the support of professionals and the wider structures of the courts and other partners.

It is too soon to judge the full impact of this service, but I have no doubt that in time it will also become an important vehicle by which a more diverse magistracy is drawn from the local community. When we see this kind of initiative replicated across the country, then we will have a big society. For example, among many of its achievements, one of the most distinct and valuable aspects of the service is its contribution to community cohesion. By placing the focus of the service on chaplaincy and creating a truly multicultural service, the Bradford Court Chaplaincy Service has made cohesion a reality. This is a service that can work across the communities of faith in Bradford and with non-believers alike. The volunteers command a range of languages and dialects, cultural backgrounds and understanding and with all this bring a unique perspective on diversity into the courts. I cannot think of many examples of statutory services that have such an eclectic and diverse make-up of staff. So I hold this service up as an example for noble Lords in thinking about these issues, an example that I hope I have demonstrated

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captures the true essence of what the big society means and how the magistracy can play a significant role in its development and realisation.

8.07 pm

Lord Thomas of Gresford: My Lords, when I was a very new, young and arrogant solicitor, I frequently appeared in the magistrates' court in the village of Ruabon in north-east Wales, an industrial part of Wales where coal was mined, steel was made, beer was brewed and chemicals were manufactured. I was always amused by the chairman of the local Bench, Lord Maelor, a former Member of this House, formerly Thomas Jones, the Labour Member for Merioneth. He lived all his life in nearby Ponciau, having worked down the pit as a young man. He later served as a non-combatant in the First World War. Indeed, he was imprisoned in Wormwood Scrubs for refusing to obey an order on the grounds of conscience. In court, he always went out of his way to identify the defendant who was before him: "Was his uncle a member of Capel Mawr?", "Did he live on Gutter Hill or was it Y Ffennant?" and so on.

Lord Maelor taught me two lessons. The first was that order is preserved in a community not by the police, but by the people: the elders, the relations and the parents. By far the worst area for vandalism and crime in the area was the brand new housing estate, Plas Madoc. It was so new that only young married people or partners lived there. Though they had moved in from the settled villages around, there were no rules, no frowns and no social disciplines in their community. The second lesson he taught me was that he would give youngsters a chance, but would follow through his sentences by his deep involvement in the community and by his continuity in office. He was the one you would come back before if you breached the probation order he was always ready to hand out.

I have been greatly helped in preparing for this debate by a study carried out by Dr Jane Donoghue of the Centre for Criminology at Oxford, which was published only last Saturday, 29 October, as Anti-Social Behaviour, Community Engagement and the Judicial Role in England and Wales. I commend the study to the Minister. She points out that a central principle of the concept of the big society is co-production: how communities and individuals connect and come together to design and produce solutions to shared problems.

In the context of the magistrates' court, the informal mechanisms of the past-that individual relationship between the magistrates and the community they serve-are of limited value in today's world. It appears that training designed by Her Majesty's Courts Service and the Judicial Studies Board in 2008 to support magistrates in community engagement has not been systematically implemented. Dr Donoghue's research shows that for the most part magistrates' involvement does not go beyond attending occasional meetings with their local ASB unit. The reverse side of that coin is that community groups have very little engagement with the courts. They live in two separate worlds.

Participants from all the 17 ASB units studied expressed their disappointment and concern that magistrates so rarely engaged with the local community, and argued that a culture change was necessary, where

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magistrates would be required to allocate time to listen to the concerns of the local community. Some said that the courts do not think about the impact of an ASB on a community, that they do not understand the effect of ASBs on certain areas and that the community has no confidence in magistrates or the courts.

On the other side, it seems that some magistrates worry about judicial independence. Dr Donoghue found that in one area magistrates discontinued an existing practice of making visits because they were concerned not to be seen to be influenced by local residents. In only one of the 17 areas studied was it felt that magistrates had a high level of engagement with the local community and were willing to talk to residents, attend local meetings and become involved in the life of the community.

The other problem identified by Dr Donoghue's research was a lack of supervision. Ten of the areas studied had no experience of any kind of the supervision of court orders by magistrates or district judges. This was because there was a significant lack of continuity between repeat offenders and sentencers. It is highly unlikely that an offender in breach of an order will be seen more than once by the same magistrate or district judge. There is no formal system in place to ensure that an offender appears before the same sentencer in every court hearing related to their case.

Dr Donoghue's conclusion is that most courts have not yet embedded into their structure the principles of community justice. Magistrates still see their role as adjudicators of fact and meters out of punishment and no more. If the concept of the big society is to have flesh put upon its skeleton, community engagement and problem solving in partnership with community groups and agencies should become a formal, standardised part of a magistrate's training and part of continuing professional development for existing district judges and magistrates.

Nobody could ever question the commitment of Lord Maelor to his community, and the result was this: clear confidence and trust in the Ruabon magistrates' court by the whole community. He did not sit above the throng; he was a part of it, and it was a pleasure to appear before him, as I have no doubt the noble Lord, Lord Elystan-Morgan, would confirm if he were here.

8.13 pm

Baroness Seccombe: My Lords, I spent over 30 years on the Bench, working with the most wonderful people. We came from a vast variety of backgrounds, all shapes and sizes, ages and colours, and reflected the community in which we lived. We had teachers, nurses, shop-floor workers, postmen, licensees, doctors, trade union officials, small shop owners-I could go on. We also had representatives of a vast number of voluntary organisations, including the WRVS, who incidentally also manned the refreshment bar. The experience they brought gave me a wealth of knowledge and added so much to our court life.

It is important to get a balance in every way in the make-up of a Bench, members having left any partiality at home, and then, working as a panel, to try to achieve a just and fair result. One of my cherished moments

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was when, as a known active Conservative, I was elected chairman. I was told the qualities required to be a magistrate were: a desire to serve the community; an ability to listen and come to a view using sound judgment; an ability to understand and to communicate; and to have commitment and reliability. Above all, I have always believed that good old common sense goes a long way.

I suppose you could say the magistracy was the original seed of the big society, having been in existence for hundreds of years, consisting of local citizens serving their local community. I believe that ever bigger and more intrusive government in recent years has sapped our strength and impeded anyone from daring to have imaginative proposals. Even if we had an idea, there have been too many obstacles in the way. For me, the big society means bringing decision-making back to communities so that local people have a real stake in running their own lives and supporting those who need a helping hand so that they can improve their lives. It means giving people the opportunity to bring colour and happiness to others less fortunate than themselves, while at the same time experiencing the genuine pleasure that can be had from joining a group of people who get things done, so contributing to a thriving community. Excessive regulation and bureaucracy have in recent years strangled initiative and enthusiasm and brought about a culture that the state always knows best. The big society is where we can all help each other as we try to do our bit to promote local well-being.

Over the years I have been saddened by the closure of so many courthouses. I was always told that the magistracy meant local justice for local offenders in a local venue, but court closures have removed that vital local component. Of course, I understand that in painful financial times difficult decisions have to be taken. My experience tells me that it will be the same people who always volunteer and who will spearhead the big society. So please, whether it is the magistracy or the big society, let us return trust to local people so that they can make their local environment work for them in a unique and distinctive way. Let us keep as little regulation in our lives as possible.

The big society is about service to others. It fosters responsibility and ever more closely weaves together an already complex and at times fragmented society. Service in all its forms is a most cherished principle that we must keep before us and applaud to the rafters. Let us ensure that we keep it small and bound to local communities.

8.17 pm

Lord Dholakia: My Lords, this debate is timely but a little premature for my contribution. Let me explain. Earlier this year the Magistrates' Association set up a public engagement programme for greater understanding of people's views on the future of summary justice and the role of magistrates. I was privileged to be asked to chair this inquiry and it is right that I record my interest at this stage. I should also point out that I have served as a magistrate for over 14 years in West Sussex.

The terms of reference of the inquiry were fairly wide:

"To inquire into the role of magistrates and the future delivery of summary justice through engaging with experts and members of the public across the country".



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We have just completed this major exercise and hope to produce our report before next April. Our intention is to inform future policy development as affecting the magistracy. To avoid any confusion, let me add that "summary justice" is a term we apply to all forms of dealing with offenders other than in the Crown Court.

The evidence was gathered by a panel comprising the chairman of the Magistrates' Association and three or four other national members involved in the criminal justice field. Local Members of Parliament played an important part in a number of consultations, with their overview of the magistracy in their constituency. The evidence-givers included local police, local victims of crime, local magistrates, professionals from intervention agencies, ex-offenders and local legal practitioners. The audience included the local public.

This has been a remarkable and informative exercise. Let me spell out some of the key questions that were addressed. Do the public still support the concept of ordinary-that is, non-legally qualified-citizens being involved as members of the judiciary in the delivery of justice in England and Wales? Do the public have confidence in magistrates? Do magistrates provide a good quality of service? What do we mean by local justice; is "local" still a meaningful concept in that context? What is the role of magistrates in restorative justice? Should magistrates be involved in pre-court or non-court activities, such as the administration of cautions and local justice panels, to deal with offenders? Should magistrates be involved more fully in the management of sentences? Should magistrates be more involved in the rehabilitation of offenders and reintegrating ex-offenders into the community? Does the make-up of the magistracy properly reflect society? Are there any barriers to achieving this? Should courts be more accessible?

Magistrates have existed, as has been explained, for more than 650 years, and we celebrated this in Westminster Hall earlier this year. In all these years, there have been many changes. At present, about 30,000 volunteers serve as magistrates. If the big society is looking for evidence of the involvement of volunteers, it need look no further; magistrates have set a very good example. We see people drawn from far and wide in our diverse community who use their local knowledge, supplemented by training provided by the Magistrates' Association and the Ministry of Justice. They contribute to maintaining peace and security in the community and deal with more than 95 per cent of cases before the courts. In the present economic climate, it is not a service that the Government can afford to pay for if they have to pay for it.

Magistrates have been impacted by a number of external factors such as criminal justice legislation, which shapes the role and functions of the magistrates. Society being able to convey its confidence or lack of confidence in the decision-making process of the magistrates is also important. This was obvious when, after the recent riots, sentencing by magistrates generated a good deal of publicity. Let me in advance of the report give a flavour of what we found during our consultation. We expected criticism, but instead we found a good deal of understanding about the way

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magistrates performed their duties. Even victims and offenders had no criticism of the way they were dealt with by the courts.

The incidence and nature of crime may vary from place to place and from generation to generation, but it is obvious that crime is something that all societies have to come to terms with in their own way. We can debate the underlying causes of crime, but most research and consultations have tended to refute rather than confirm the causes of crime and the effectiveness of punishments and treatment. Magistrates tread delicately but effectively, particularly when the public and political mood continues to be conditioned more by tabloid reporting than by the considered way in which magistrates reach their decisions.

It is not possible to elaborate more fully at this stage on a number of our findings, but I trust that my noble friend Lord McNally will offer us the first opportunity to debate and discuss the report with his department. Suffice it to say at this stage that there was an emphasis in its broadest sense of diverting as many young offenders as possible from the criminal justice system. This is not a soft option but an entirely realistic approach to the strictly limited contribution that courts and prisons can make to reduce crime. We were told repeatedly that local justice should remain local in a magistracy that is representative of our diverse society. It is important that liaison with the probation service is enshrined in its duties and that its role should define the extent to which it should be involved in restorative justice, pre-court and non-court activities, the management of sentences and the process that rehabilitates offenders.

In conclusion, the time is right for politicians and others to secure a clear shift in the public's perception of crime and punishment. Six hundred and fifty years of history and more than 30,000 volunteers as magistrates are the envy of the world. Let us make sure that they are not ignored in the challenging times ahead.

8.24 pm

Lord Phillips of Sudbury: My Lords, I thank the noble Lord, Lord Ponsonby of Shulbrede, for instituting this debate. In the limited time that I have, I would just like to endorse the point, which was made very forcefully by the noble Baroness, Lady Seccombe, and others, that local justice is the essence of the work of justices of the peace. I have the greatest conceivable regard for the magistracy system, which has served this country for nearly 800 years, stands high in the reputation of the public, delivers the most extraordinary service, and itself is a demonstration of volunteerism that all recognise.

However, the centralisation of the Courts Service has brought about serious drawbacks both to the public and to the magistracy. It is no longer justice of the people, by the people and for the people. The non-reporting now of cases because they are no longer within the purview of the local newspaper has been a disaster for the greater punishment of someone being held up to local ignominy as a result of a local offence. That is almost gone from the town I live in. Indeed, every one of the four courts in which I spent most of my first five years in the law-Sudbury, Long Melford,

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Boxford and Hadleigh-closed, and justice is no longer accessible, geographically or psychologically. I realise that this is more a problem of rural than of urban areas, but I ask that the Government take on board what has been said in this debate and at least stop further court closures and expensive centralised court systems and go back, wherever they can, to the dual or triple use of buildings, which rendered the expense of magistrates' courts absolutely minimal.

I have two other quick points to make.

Lord Wallace of Saltaire: My Lords, we are very short of time in this debate.

Lord Phillips of Sudbury: I was told that I have four minutes but will take less time if I can.

My first point is that unless the public understand the role of the magistracy, the magistracy will not be able to do its work as effectively as it has in the past. I fear that young people today do not by and large understand, largely because of the centralisation of courts, the role of JPs and the work that they do. I hope, therefore, that my noble friend Lord McNally will take back to Mr Gove, his colleague in the other place, the importance of maintaining citizenship education as a compulsory component of secondary education, because that is one upholder of knowledge about magistracy and magistrates' courts.

My second point relates to the magistrates' courts mock trial competitions that are currently being run by the Citizenship Foundation-I speak here as its founder and still president-and the Magistrates' Association. More than 400 schools and 6,000 pupils are involved. It is a massively important element of the education of the public about the magistrates' courts system, but it is in danger because of the withdrawal of funding.

I will say no more because I am getting serious looks from the Front Bench.

8.28 pm

Lord Kennedy of Southwark: My Lords, like other noble Lords before me, I start by thanking my noble friend Lord Ponsonby for initiating this debate on what plans Her Majesty's Government have for the magistracy in the big society. It is a timely debate and we look forward to the Minister's response.

I served for a number of years as a magistrate as part of the Coventry Bench and I have direct first-hand experience of the work, and the dedication to that work, of magistrates up and down the country. As my noble friend Lord Ponsonby said, magistrates, or justices of the peace, have been around for 650 years. They were "good and lawful men" back in the 14th century-and they were all men then-appointed to every county to "guard the peace". Perhaps it could be said that they were the trailblazers for the big society, or its original seed, as the noble Baroness, Lady Seccombe, said. I pay tribute to the work that they have done and continue to do to this day. They are men and women living locally, giving their time freely, committed to sitting a minimum of 26 half-days a year, and making a real positive contribution to their community. They are delivering local justice for local people by local

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people. The former Lord Chief Justice, Lord Bingham of Cornhill, observed that the lay magistracy was a "democratic jewel beyond price".

Noble Lords will be aware that all criminal cases start in the magistrates' court and that more than 95 per cent are concluded there. At this point, I pay tribute to the work of the Magistrates' Association in the support, advice and guidance that it gives magistrates. It was 90 years old recently and has made an important contribution to the development of the magistracy over that time.

The big society as an initiative is something that we hear less about from the Government today than we did at the start of their period of office. But we can all point to organisations, people and initiatives that make a welcome and positive contribution to local communities, and lay magistrates fit that bill wonderfully. Magistrates are appointed by the Lord Chancellor and the Secretary of State for Justice on the advice of local advisory committees. The appointments process is rigorous in its approach of selecting the right people to undertake this important work.

Having an appointments process that is rigorous and robust but also adaptable is paramount to ensuring that we make the best appointments. Can the noble Lord, Lord McNally, tell us if the Government are looking at the appointments process of both lay magistrates and the advisory committees to ensure that we have the best chance of appointing people who truly reflect their local communities? How are the Government engaging with employers and the voluntary sector to ensure that there is a steady stream of applicants? Are they working with, for example, local Sure Start centres to get younger women with children to consider putting themselves forward as magistrates? My noble friends Lord Patel and Lord Ponsonby made important points regarding diversity.

I am sure that noble Lords are aware of the Magistrates in the Community programme, which was started by the Magistrates' Association. In recent years it has increased the public's awareness of the role of magistrates in the criminal and civil justice system. It involves magistrates attending schools, colleges, community groups and employers to give presentations and to discuss what magistrates do and how they are appointed.

Quite rightly, the Government want to make good use of community sentences. The local crime community sentence programme builds on the success of the Magistrates in the Community project and involves magistrates and probation officers together speaking to community organisations to deliver information on how offenders are dealt with when they have committed a crime that has resulted in a community punishment. When the noble Lord, Lord McNally, responds, can he tell the House what value the Government attach to these initiatives? What support are they giving them and what do they see in terms of further development?

Both the previous Labour Government and this Government recognise the importance and worth of real community engagement in criminal justice strategies. It can increase confidence in the criminal justice system and help to diminish anxieties about crime, although some would say-I should say at this stage that I do not agree with them-that this raises concerns about

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judicial independence, as the noble Lord, Lord Thomas of Gresford, told your Lordships' House. It is an obvious and natural progression, and essential for enhancing community confidence in the justice process. Can the noble Lord also give some insight to the thinking of the Government and perhaps tell the House how he sees this being further developed? When does he expect the training material and other briefing devices to be fully reflective of this?

In conclusion, I am aware that I and other noble Lords have posed a number of questions to the noble Lord, Lord McNally, and it may not be possible to answer all the points in the time that he has. If that is the case, I should be delighted to receive responses to the points raised in writing. I again thank my noble friend Lord Ponsonby for initiating this debate. We have had excellent contributions from all around the House and, like others, I look forward to what the noble Lord, Lord McNally, has to say.

8.33 pm

The Minister of State, Ministry of Justice (Lord McNally): My Lords, first, I thank the noble Lord for the courtesy of those last remarks. Indeed, if I am to sit down at the right time, I will not be able to cover all the points that were made. However, I will write to all noble Lords if I do not manage to cover all the specific points. I also thank the noble Lord, Lord Ponsonby, for introducing this debate. As he knows, my first job in politics was working for his late father, who I am sure would have been proud to see the noble Lord introduce this debate. I am also grateful that we have had the experience of a number of magistrates, including the noble Lord, Lord Ponsonby, my noble friends Lady Miller and Lady Seccombe, and the noble Lord, Lord Kennedy of Southwark.

One of the concerns raised by the noble Lord, Lord Ponsonby, was the poor administration of the court system. We are looking at that in terms of introducing new technologies as well as perhaps also bringing forth legislation at some stage to improve court management. I agree with him that courts should retain the personal touch; I take that point. The noble Lord, Lord Ponsonby, and a number of other noble Lords referred to community sentencing. He is right that I want us to explore more community sentencing. However, as the noble Baroness, Lady Miller, reminded us, if such sentences are to carry public respect they will have to be tough and effective.

Noble Lords referred to diversity. At the Ministry of Justice I am the Minister with responsibility for encouraging diversity. It has to be said that one of the encouraging things about the magistracy is that it is a whole lot more diverse than other parts of the judiciary. Other than make that point, I shall say no more. A number of good suggestions were made this evening. I will not make the usual point that times are hard and question whether we can afford to advertise on buses. However, I will take back the suggestions made by the noble Lords, Lord Ponsonby and Lord Kennedy, and others about how we encourage technology.

I hear what the noble Baroness, Lady Seccombe, and my noble friend Lord Phillips said about court closures. There is a whole variety of reasons why we

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have moved to court closures, including the inadequacy of some of the older courts and the increased use of technology. We will explore that, and I think it will be a factor in making the courts more accessible.

On recruitment and retention, I know that my honourable friend Jonathan Djanogly and my right honourable friend Nick Herbert in the other place are in close and regular contact with the Magistrates' Association. Indeed, Nick Herbert is addressing the Magistrates' Association conference on 8 December. However, I take the point that the noble Lord, Lord Kennedy, has made. I will go back to the department to see how much outreach we are making. It is extremely important that we encourage as many people as possible to come forward in terms of encouraging diversity.

I was fascinated by the comments made by the noble Lord, Lord Patel, about the court chaplaincy service. In the big society, the churches, the religions and the faiths have a big part to play. They already have a structure of which we should make use. Two of the most fruitful visits I have made were to Norwich and St Albans, where the cathedrals are used not just as faith centres but as community centres. What the noble Lord described about the chaplaincy service seems to be an inspirational example of how this could happen.

The noble Lord, Lord Thomas of Gresford, made two points. The first was his memories of the local magistracy. My colleagues back at the MoJ are aware that I frequently refer to Tommy Croft and Billy Quinn, although they are not names that have run down history. I was born on an ICI estate and Billy Quinn and Tommy Croft were two local magistrates. They both worked in the local ICI plant but, my God, they knew the community and their community knew them, which is always an interesting aspect of the magistracy. On Dr Jane Donoghue, I have not had the benefit of that study but I will certainly follow up on that. From what the noble Lord had to say, there are some interesting points about training and engagement.

We welcome the research referred to by my noble friend Lord Dholakia in his intervention. I think that it will help to inform our thinking on the future of the magistracy, particularly in relation to plans for developing neighbourhood justice. I certainly hope that when the report is ready, we will have a dialogue on it. I would welcome that.

It has been pointed out a number of times that this year is the 650th anniversary of the magistracy. I was pleased to be at the John Harris Memorial Lecture given by the Lord Chief Justice on this. As someone who is a kind of fake historian, I liked the idea of the concept of the King's peace being set in statute in 1361 and the novel proposition that decent members of the community, not themselves lawyers, should be vested with the power to administer justice. That is one of the things which has been of lasting value to the magistracy. It comes from local communities and its strength lies in the fact that it is still the bedrock of our judicial system. My noble friend Lord Phillips referred to the mock trial competition. It is true that we have had to reduce our support for that. We still give it money and of course we also provide the court and staff for the competition, so we have not abandoned it entirely.



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As the noble Lord, Lord Kennedy, intimated, the problem with these dinner time debates is that to do justice to those who have contributed, the Minister should really be given half an hour to speak, but I will cover some of the issues in writing. What I would say, however, is that my gut instinct, going back to Tommy Croft and Billy Quinn, is that as long as I am a Minister, I will take the role of the magistracy as the bedrock of our criminal justice system. Some of the ideas put forward in the debate tonight will be taken back and studied very carefully. What I want to say as well is that although we are looking at other proposals such as neighbourhood justice and restorative justice, they will be seen as complementary to and in no way undermining the magistracy. I look forward to a dialogue with the magistracy and I will study the suggestions that have been made in this debate, not least those on how we achieve greater outreach so as to increase diversity. Again, I thank sincerely the noble Lord, Lord Ponsonby, for promoting a debate which has been extremely worth while.

Health and Social Care Bill

Main Bill page

Committee (2nd Day) (Continued)

8.43 pm

Amendment 12

Moved by Lord Warner

12: Clause 2, page 2, line 16, at end insert-

"(c) the clinical integration of the delivery of health and social care"

Lord Warner: My Lords, as they say in commercial television, welcome back after the break. In moving Amendment 12, I shall speak also to Amendments 16, 17, 182, 183 and 184 tabled in my name and those of other noble Lords. I have also added my name to Amendment 18 to which my noble friend Lord Rooker will speak-I hope. The theme of these amendments is that of giving greater prominence in the Bill to the issue of service integration not just within NHS services, but across the health and social care boundary. At the same time, I will try to give some clearer meaning to this term by offering a definition in Amendment 184. This is a very complex issue and it has not been helped, if I may say so, in some of the public discourse by the way that the term "integration" has been used in a wide variety of ways by different people.

I shall start with some remarks about integration and its relationship to competition, which has been the subject of quite a lot of debate around this Bill and NHS reform. In recent months, the term "integration" has been bandied about as a kind of panacea for the NHS in the challenges it faces, but with little clarity about what it means. The Future Forum put the issue of integration on the map in its report. Some of this affection for integration has grown because it has been seen as a useful term by opponents of competition. They have tried to make the argument stand up that somehow if you have integration of services, you cannot support competition because the two are incompatible. I do not believe that to be true. It is

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perfectly possible to have the right kind of integration within a competitive market. Kaiser Permanente, among others, has shown this to be the case in the United States. Indeed, it was the very competitiveness of that market which caused Kaiser to offer patients more clinical integration in order to survive and flourish in the marketplace. That integration was done on the basis of reducing the use of in-patient hospital services. It is worth noting that there are NHS-Kaiser Permanente partnerships in six areas of the NHS which are adapting lessons from Kaiser's experience in the US to apply in this country.

Having got that off my chest, I turn now to the issue of how integration and competition can coexist and how we need to be clear on what we are talking about when we use the term "integration". There is, I suggest, good and less good integration. Much so-called organisational integration is effectively mergers of providers with little benefit to patients and often involving a reduction in choice. We see this in integration horizontally across organisations of the same kind and vertically between community and hospital services. The former is often done to save costs and reduce competition, while the latter is too often a way of securing patients for in-patient services and maintaining hospital income. Some will disagree with that, but it is certainly a perspective we should think about. Organisational integrations of this kind have sometimes fallen foul of the competition and collaboration panel. They are to be viewed with a sceptical eye, although I accept that integrated commissioning can be a major benefit for patients.

The integration, however, that is likely to benefit patients the most, and the cost structure of the NHS the greatest, is integration that brings together the assessment and delivery of health and social care services at the point of assessment and delivery to the individual person. This is the type of integration we have attempted to define in Amendment 184. At a time when such a large part of the NHS's work involves patients with long-term conditions, who often require social care as well as healthcare, this is the type of integration that NHS and social care organisations and personnel should be focused on, particularly those commissioning services. These commissioners need to look for a new breed of service integrators who can take responsibility for integrating services for individuals across the health and social care boundary or divide, depending on your perspective. The Conservative's community care reforms of 20 years ago produced care managers as integrators of social care in a mixed economy of providers. We now need to apply the same thinking to the whole spectrum of health and social care, especially for those with long-term conditions.

None of this will be easy, but if the NHS is to meet the financial and other challenges it faces and reduce its dependence on expensive, often unsustainable and often inappropriate, acute hospital services, it must begin the process of improving service integration at the level of the individual and not just the organisation. It is important that we use the Bill to set a new direction of travel on service integration for both the NHS and the social care worlds. The word "integration" needs to move from a term of rhetorical flourish to a reality that benefits people at the local level.



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Of course, simply putting words in a Bill will not on its own change things; they will need to be backed up by changes in the professional culture, the use of IT and the financial reimbursement system. Later in the Bill I shall move amendments to help integration in the areas of tariffs and the use and extension of an electronic patient record. In the mean time, I want to establish a bridgehead in the Bill with this group of amendments that give more prominence to integration and try to define it. My co-signatories will expand on some of the arguments.

I should make it clear that I do not regard the wording of these amendments as the last word on the subject. I am sure they could be improved and they may have consequences for other parts of this leviathan of a Bill that we have failed to spot. I also recognise that the Labour Government had integrated care organisation pilots and that the Department of Health and the King's Fund are working on the issue of integrated care following the Future Forumreport. It is no purpose of these amendments to pre-empt or damage that work. I and my co-signatories are seeking to establish today whether the Minister is up for amending the Bill to give more prominence, more precision and greater reality to the term "integration" to shape the future commissioning and provision of services in ways that will benefit patients. We will be glad to sit down with him and his officials to improve the wording of the amendments and their placement in the Bill. I beg to move.

Lord Patel: I support the amendments to which my name is attached. This is an important issue. As the noble Lord, Lord Warner, mentioned, at some of the seminars we heard the word "integration" used in different forms with no clear definition of what it meant.

Future Forum, of course, put integrated care at the heart of NHS reform, but who will ensure that integrated care is not crowded out by the emphasis on competition and any qualified provider? What can clinical commissioning groups do to stimulate providers to work together to meet the needs of the patient?

As the noble Lord, Lord Warner, mentioned, integrated care takes many different forms and may involve whole populations; care for particular groups or people with the same diseases; and co-ordination of care for individual service users and carers.

There is good evidence of the benefits of integrated care for whole populations and for older people. There is mixed evidence of its benefits for people with long-term conditions such as diabetes and for people with complex needs. I will return to that later. Of course, Kaiser Permanente is one of the good examples of managing integrated care for long-term conditions but there are not that many.

The commissioning groups will need support from the NHS Commissioning Board as they set about commissioning integrated care. That includes advice on matters of contracting and procurement, outcomes and quality measures to include in contracts, and the tariffs and incentives to use. Work is also needed on how to create the right incentives to support integrated care. Payment by results was designed primarily to support choice and competition in relation to elective

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care. Alternative forms of payment are required to support integrated care, especially for people with chronic diseases and to support more co-ordinated, unplanned care when funding is tight. That will have to involve the providers.

Other factors that appear to support integrated care commissioning include robust performance management, sufficient time and resources from the provider side, and adequate investment in the main stages of the commissioning cycle, such as needs assessment, service design, contracting and tendering, and outcome-based evaluations. As management and resources shrink, there are obvious questions about whether clinical commissioners will have the necessary time and support to plan and contract for changed services in profound ways. To be more specific, there need to be resources at a national level to avoid commissioners at a local level reinventing the wheel many times over.

To turn briefly to long-term conditions, in the next decade the health and social care system will have to contend with an ageing population, increasing numbers of people with complex long-term conditions, budget constraints, increasingly sophisticated and expensive treatments, and rising expectations of what healthcare services should deliver. An integrated care approach to meeting these challenges-through better co-ordination of health and social care services, reducing the fragmentation or duplication of care-has the potential to improve support for the management of these complex needs.

Let me share a true story as an example of the issues here. Somebody approached me just before Second Reading of the health Bill. I mentioned this at one of the seminars and have since checked the authenticity, and visited the person in the hospital where care is currently provided. This person has insulin-dependent diabetes and was found to have an ulcer on the leg. He saw his GP who suggested that dressings would be required to try to heal the ulcer. During the process of that treatment, a specialist diabetic nurse who came in contact with the person suggested that they might be better getting advice from a specialist unit. While the GP suggested that the care provided was satisfactory, the person demanded to be referred to a hospital. By the time he got to the hospital, three of his toes were necrotic. They had to be removed last week. The patient needed an angiogram to decide whether the blood flow was satisfactory so as to put stents in so that he would not lose further parts of his limbs.

As we all know, it is crucial for diabetic patients to avoid certain complications. Good glycaemic control is required to manage that, so that their sight and renal functions do not deteriorate, their cardiovascular functions remain good and they also do not lose limbs because of necroticism. This shows the need for integrated care that requires the whole team to work together. For a start there need to be good records and IT that can transfer information between different carers, GPs, practice nurses, specialist nurses, and specialists in diabetes. There needs to be screening for eyes, kidneys, blood pressure, diet, cardiovascular disease and so on. Most importantly, there needs to be joint training for people who look after these patients, whether that is in the community or in specialist units.



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If you are looking for good outcomes for patients, integrated care is what matters. It should be based on the journey of care-the patient pathway of care. That is what we need to establish. I hope, as the noble Lord, Lord Warner, said, that we can have further discussion to try to improve this Bill and see if we can deliver that.

9 pm

Baroness Murphy: My Lords, this is a topic very close to my heart. The delivery of social care is almost wholly towards people with health problems; if you do not have a health problem, a disorder or disease, you will not be in receipt of social care. But we have always had this curious distinction between who delivers what. We have had these great silos whereby enormous amounts of spending in the health service would be better spent transferred to social care services. We have known that for years and years, but it has not really happened as fast as it should have done.

The commissioning and delivery of services has been almost wholly down these isolated silos. We have tried to chisel away at this over the years with joint trusts for delivery of services to children and other joint trusts for delivery of services to mental health, and so on. But for the mainstream older person coming through healthcare services, we have not had that integration very effectively, and we have therefore wasted money buying health services when we should have been buying social care services. So it is crucial that people get better cost-effective packages of care, which include the whole pathway.

It is also true that we have a system at the moment whereby in the past 20 years we have moved hundreds of thousands of seriously disabled older people out of NHS care into independent sector nursing homes and, in the beginning, local authority care homes and contracted private homes, leaving behind the teams of people-healthcare professionals, medics and nurses who used to care for them in hospitals-completely isolated back in the hospital. They are not delivering those community services that the independent sector nursing homes and local authority care homes so desperately need to provide-comprehensive health and social care service in residential care. It has always seemed extraordinary that we have allowed these silos to grow up, whereby the person sitting in the hospital, the consultant geriatrician or the psychogeriatrician, does not think that it is their business to provide a service for the wider community of patients in their patch. It seems extraordinary to me that we could have got ourselves into this position.

We need something to move back again to a situation in which people think epidemiologically about a community, about how the best services could be provided from vertically integrated care between hospital and community services-and of course that community care must start with what comes from primary care-but also fundamentally from what is commissioned from social care as part of the package. Perhaps we can get it in somewhere in this Bill that we need to do this. We all know about Kaiser Permanente and the examples of how it works in the States. It works very effectively when you can commission from a range of services across health and social care directly. That makes a

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great deal more sense than trying to narrow the trenches; a trench always pops up somewhere else when you chisel away at a trench between local authorities and NHS authorities. You do not need to do that if you are very clear about commissioning a package of services across the divide and across NHS primary care and social care. This is extraordinarily important as the population continues to age and, without it, we will not be able to generate that wonderful £20 billion of savings that we are always going on about. We will get better value for money if we contract across an integrated care pathway across health and social care.

I do not know whether this is the right point to get this proposal in. Like the noble Lord, Lord Warner, I am sure that it should go somewhere and that we should have a real commitment in the Bill. If it is the right point, we can get people to translate this into the sort of unbundled tariff that we need to get the financial packages right and move away from the counterproductive system of payment by results. Unfortunately, that again tends to fossilise an old-fashioned way of doing things, which is too expensive. I give my full support to this amendment.

Baroness Pitkeathley: My Lords, my name is added to some of these amendments and I will add little to the eloquent speeches of my noble friend and of the noble Baroness and the noble Lord from the Cross Benches. I want to endorse only the important points of principle that they have set out. As someone who has spent a large part of a long working life at the margins or the crossover points between health and social care, I am only too well aware of what goes wrong if you do not have proper integration. It is very important, as the noble Lord, Lord Patel, reminded us, to come at this from the experience of the patient, the user and the carer. Their needs rarely come neatly packaged as health and social care; there is always crossover between them. That is especially true in the case of long-term illness but it is also a concern to those who have had an acute episode, especially in these days when people are discharged early from hospital but still need medical, nursing and social care at home.

Almost 40 years ago, I wrote a book called When I Went Home, a study of patients discharged from a local community hospital. One patient I interviewed said to me, "What I don't understand is why they don't talk to each other. Why did they discharge me without arranging it with my family-without even telling my family I was coming home-and why weren't the services I needed at home all geared up for when I got there?". I have lost count of the number of times that I have heard this story repeated over the years. Patients, users and carers do not understand different funding mechanisms, professional boundaries or sensitivities about exchanging information-and why should they? We have been saying for at least 40 years that we must improve integration. Let us for goodness' sake use this reform as a means of achieving more commitment to integration, to which everyone pays such a lot of lip service but which in reality is still sadly lacking.

I must emphasise that we are at a point where not only do we risk not making integration better but where it could become worse if we do not really emphasise

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the importance of integration in this legislation. I am thinking of things such as the pressure on local authority budgets and on the voluntary sector, which is so often such an important part of an integrated care package. I am thinking of the mismatch in timing between the reforms in social care and those in the health service. I always think, too, that we should remember that it is people, not structures, who promote integration. Those currently employed in health and social care are working in a confused situation. They are often uncertain about their futures and their working relationships. They are therefore really not in a good place for cutting across professional boundaries and perhaps giving up some of their power to develop the flexible ways of working which are so necessary for integrated services. We owe it to them, as well as to the patients, users and carers, to be as explicit as possible about the importance of integration. I hope we will do that in this Bill.

Baroness Cumberlege: My Lords, I would like to make a contribution. I was very interested that the noble Lord, Lord Warner, said in his introduction that he felt that integration was sometimes used as a defence against competition. He cited Kaiser Permanente, as did the noble Lord, Lord Patel. Closer to home, I was really interested to see that Assura Cambridge-Assura is an independent company-was involved in an integrated care organisation. It was a pilot that was designed to improve the quality of end-of-life care locally and to ensure that 50 per cent of patients who knew they were dying would do so in a place of their choice. After five years, the aim is to increase this figure to 75 per cent.

Assura Cambridge, which is a partnership between Assura Medical and 16 GP practices in Cambridge, worked with a range of care providers to plan, co-ordinate and improve the delivery of care to patients in the last year of their lives. The project team was led by Assura Cambridge and included representatives-this is important because it shows real integration-from Cambridge University Hospitals NHS Foundation Trust, Cambridge Community Services, NHS Cambridge, which is the primary care trust, the Cambridge Association to Commission Health and the DoH integrated care organisation pilot team. This collaboration and partnership had a very simple system, which was to use "just in case" bags. The system was adopted to ensure that GPs had the appropriate medicines to hand for terminally ill patients in advance of their need. By taking this very simple step, the integrated care organisation was able to ensure that 87.5 per cent of deaths occurred in the patient's usual residence or place of choice, compared to only 50 per cent of deaths without using the system.

In this case it was Assura Medical that acted as the glue to ensure that collaboration brought about an integrated solution, which has since exceeded the project's aspiration. That is very interesting: it needed someone from outside the NHS to bring all these people together. When I talked to some of them, they said, "We haven't got the time to do that. We just couldn't fit all that together". It was an outside organisation that was able to do that.

Recently I went to the Royal College of GPs' annual conference in Manchester-no, I am sorry, Liverpool; I know there is a great difference between the two, but

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I have been travelling a lot recently. There was great debate about the ethical issue of GPs commissioning. The person promoting this was Professor Martin Marshall. He asked the audience of GPs-the place was packed-what the most frequent diagnosis that came through their surgery door was. As you might expect, the GPs mentioned coronary heart disease, diabetes and so on. Professor Marshall said, "No, it's LIS", and everyone looked very puzzled. He said, "Lost in the system". I thought that was interesting. "Lost in the system" is the problem when we do not have integration.

It seems to me that integration happens on three levels, so maybe we have to define it more closely. The first is within community services. A GP said to me the other day, "District nursing-they're the enemy". When you start at that base, we have an awful lot of work to do just to get integration within the community. As the noble Lord, Lord Patel, said, you have to get the whole team to work, and to work beyond the team as well.

I have done a bit of work with maternity services. This is the next tier up-integration between community and hospitals. One of the things that we have tried very hard to do is to get midwives to have caseloads, so that they are there when the woman is pregnant, looking after her. They will perform the delivery, which will not necessarily be at home-it can be in hospital-and then do the postnatal care. It is brilliant. It is what women want and it provides continuity and integration. Try getting that to work-it is very difficult, because of the territories; hospitals often do not want the community midwives to come in, on to their territory, and perform the delivery. Integration happens in some places but it is very hard to roll out. That is the second tier-the hospital and community tier.

9.15 pm

The third tier comprises social services and health and is a very difficult area, as the noble Baroness, Lady Murphy, said. It is about silos and hierarchies. It is not just about territories; it is about who employs the staff. Having spent a few days in Torbay, I was very interested to see that the social workers there are now employed by the PCT. The social workers have been TUPE-ed across. A single organisation employs both health and social services staff. I went to some of their meetings and was very impressed by the integration that they had achieved. That was very encouraging.

I note that new Section 14Y on page 37 contains a duty to promote integration as regards CCGs. Subsection (1) states:

"Each clinical commissioning group must exercise its functions with a view to securing that health services are provided in an integrated way where it considers that this would-

(a) improve the quality of those services",

and reduce health inequalities. The new section goes on to say a bit more about integration with social services. Health and well-being boards have a duty to encourage integration under Clause 192 on page 193. Subsections (1) to (4) of that clause contain a lot of detail on that duty. Clearly, there is a great will within the Government to achieve integration. I am sure that the noble Lord, Lord Warner, who is extremely persistent and determined, will keep up the pressure in this regard and we will see how this all pans out.



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