Health and Social Care Bill

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 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. 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. 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 Prime 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 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.