EU: Mental Health (EUC Report)

– in the House of Lords at 7:23 pm on 17th October 2007.

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Photo of Baroness Thomas of Walliswood Baroness Thomas of Walliswood Spokesperson in the Lords, Women and Equality 7:23 pm, 17th October 2007

rose to move that this House takes note of the report of the European Union Committee, Improving the Mental Health of the Population: Can the European Union help? (14th Report, HL Paper 73).

Photo of Baroness Thomas of Walliswood Baroness Thomas of Walliswood Spokesperson in the Lords, Women and Equality

My Lords, in January 2005 a conference of European health Ministers, convened at Helsinki by the World Health Organisation, issued a declaration acknowledging the fundamental importance of mental health and well-being to the quality of life and economic productivity of both families and nations. The European Commission was asked to support the WHO's initiative and, in October 2005, published a Green Paper, Promoting the Mental Health of the Population:Towards a Strategy on Mental Health for the European Union. This report is the Select Committee's response to that consultation.

At the start, Sub-Committee G, which handled the inquiry on behalf of the Select Committee, was apprehensive about the task ahead. Written evidence seemed to suggest a wide role for the EU, whereas we were concerned to ensure that the role of member states, as the sole authority for health care delivery within their borders, was not overlooked. Members also felt a certain hesitation at taking on a subject matter as complicated as mental health and its treatment. However, once we started to take evidence, we realised, first, that the Commission was fully aware of the issue of subsidiarity and, secondly, that the European Union did have an acceptable basis for playing its part in improving the mental health of the population.

The background to the Commission's consultation paper is the magnitude of the problem of mental health, or lack of mental well-being, across Europe. According to work published by independent researchers in the respected journal European Neuropsychopharmacology, about one in four adult Europeans suffers from some form of mental ill health in any one year. In this context, it is important to understand that mental ill health can range from such things as stress or depression—sometimes referred to as loss of mental well-being—to the most serious disorders requiring prolonged treatment in hospital or in the community. The costs arising from such a heavy incidence of ill health include the suicides of some 58,000 EU citizens every year and heavy economic costs relating to loss of output, the costs of medical care and a monetary valuation of the intangible human costs of disability, suffering and stress. The Sainsbury Centre for Mental Health has estimated that these costs amount to £77 billion per annum in the UK, notwithstanding that the UK has a lesser incidence of mental illness than some other EU member states.

A second problem is the stigma attached to those who suffer from mental illness who, unlike those with physical illness, may experience ridicule, prejudice and discrimination. An example of this stigma is the difficulty of re-entering employment after a bout of mental ill health. The UK Government's 2004 Social Exclusion Unit report, Mental Health and Social Exclusion, found that fewer than 40 per cent of employers would consider employing a person with a history of mental illness compared with more than 60 per cent who would employ somebody with a history of physical illness. The noble Baroness, Lady Neuberger, will deal with this aspect of the problem.

At the same time, the treatment of patients with mental health problems is under examination across the EU and in many other parts of the world. Efforts are being made to treat patients in the community rather than in hospital, to examine, improve and extend the use of what are sometimes called the talking therapies, and to persuade the population at large to regard other people's mental illness in a more tolerant and understanding way. In the UK, relevant legislation was going through Parliament at the same time that Sub-Committee G was dealing with the Commission's consultation paper, and the noble Baroness, Lady Howarth, will, I hope, consider this interaction in her speech.

Bearing in mind the exclusive competence of member states of the EU for the organisation and delivery of healthcare and the direct role of the WHO in advising member states on the medical issues of healthcare and treatment, the question arose as to what input the EU and its institutions could make to the amelioration of these difficulties. However, all the evidence to our enquiry was that there is a clear role for the EU in providing practical support to member states within a number of competences in, for example, employment, social affairs, equal opportunities and research and information. In addition, the EU provides a unique forum, not only for interchange of information about best practice in treating mental illness, but for the representation of those who represent patients and their carers. That group of people were particularly keen that we should be enthusiastic about the Commission's proposals.

The main conclusions of the report are contained in Chapters 4 to 10. I shall consider them briefly, because it is a dense report and noble Lords might otherwise find it difficult to get a picture of it. Chapter 4 deals with the question of competence and advises the Commission to consider carefully its final proposals in this context. But the Committee felt that the EU role would add value to that of the WHO by concentrating on areas such as economic costs and citizen's rights alongside the role of the WHO, on the one hand, and the responsibilities of the member states, on the other.

Chapter 5 deals with the human rights issues and supports the view that appropriate deinstitutionalisation, minimal use of compulsory treatment and good care in the community should form part of any balanced scheme of treatment for the mentally ill.

Chapter 6 deals with social exclusion, stigma and discrimination and broadly supports the Commission's proposals to address this problem. We draw attention to specific problems, such as the number of prisoners with mental health problems and the need for positive action to change public attitudes to people with mental illness. The Committee also felt that discrimination against those suffering from mental illness should be dealt with under anti-discrimination legislation and that the effect should be monitored.

On discrimination in the workplace, we recommended support for joint working with employers, with particular attention paid to finding practical measures to help small businesses.

The final recommendation in this chapter was that the European Commission should consider introducing a reporting obligation for member states to monitor how employers are performing in relation to the employment of people with mental health problems. Since the publication of the report, the Commission and the Government have both responded to our recommendations. It is interesting that the only point of concern raised in the government response relates to this recommendation, which they seem to see as unnecessary. Perhaps the Minister will be able to clarify this point when she replies to the debate.

In Chapter 7, we recommend that the Commission encourages national Governments to improve early identification and intervention services and support the Commission's proposal to bring together different directorates in a common approach. The Commission's ability to work across the directorates in this manner is very relevant to the work that it can do in this context. We welcome the Commission's intention to bring together specialists from across the EU to learn from best practice with respect to early intervention.

Chapter 8 deals with the mental health of specific groups, especially children and adolescents, older people, people from different ethnic groups and women. We drew attention to the need to think about the different strategies and approaches that would suit these different groups.

Chapter 9 deals with a problem set by the Commission paper and by several witnesses concerning whether it would be appropriate for the Commission to set minimum standards of treatment. We concluded that that would not be suitable. However, we welcomed the suggestion that a set of general principles should be established covering many of the matters, such as where patients should be treated, access to evidence-based treatments, protection of human rights and efforts to reduce stigma, to which reference has already been made.

Finally, in the last chapter, the committee considered the need for better statistical information across the EU. We recommended that the Commission encourage member states to improve their statistical reporting and that it should itself collect comparable information on mental health policy and practice to underpin international and national strategies to improve the mental health of the population.

Since the publication of the report, we have received responses from both HMG and the Commission, and these were, with the exception of the point dealt with above, supportive of the work done by the sub-committee. The next step is for the Commission to publish a new communication containing proposals for measures to carry the World Health Organisation process further within the European Union. Meanwhile, noble Lords may be reassured to hear that this process is taking longer than one might otherwise expect, because ours is not the only report to have emphasised the need for the Commission to respect the responsibility of member states for the organisation and delivery of healthcare services.

At this point, I acknowledge the great assistance given to the sub-committee not only by those who appeared before us but also by the many people and organisations that responded to our request for written evidence. Members of the sub-committee are also immensely grateful to our special adviser, Martin Knapp, Professor of Social Policy at the LSE, and for the efficiency, energy and support provided by the two Clerks to the sub-committee, Gordon Baker and Barry Werner.

This is the last time that I shall address your Lordships' House as chairman of a sub-committee of the European Union Select Committee. I thank all the Members who served with me in that committee for their support, for the fun that we had and for the business that we got through. I beg to move.

Moved, That this House takes note of the report of the European Union Committee, Improving the Mental Health of the Population: Can the European Union help? (14th Report, HL Paper 73).—(Baroness Thomas of Walliswood.)

Photo of Lord Northbourne Lord Northbourne Crossbench 7:33 pm, 17th October 2007

My Lords, I shall not delay the House long as I have only one point to make. However, I should make it clear that I do so not because I do not believe that mental health is important but simply because I recognise that I have no special expertise in the subject in general.

The report devotes only two out of 110 pages to the problems of children and adolescents. That is disappointing, but at least it makes clear the importance of mental health problems for that group. For example, the Commission's Green Paper is quoted as saying that,

"as mental health is strongly determined during the first years of life, promoting mental health in children and adolescents is an investment for the future. The view is taken that teaching parenting skills can improve child development; and that attention to these issues in schools can increase social competencies, improve resilience, and reduce bullying, anxiety and depressive symptoms".

One witness said that as many as one in 10 children in the United Kingdom may develop mental health problems today. There seems to be a very strong case for more resources to be devoted to children's mental health.

Perhaps I may quote once more from the report concerning evidence submitted by the King's Fund. It was noted that today,

"mental health resources in Europe were concentrated on working-age adults with enduring mental health needs", and the King's Fund,

"wanted the EU strategy to emphasise the need to support children and older people among whom numbers of mental health problems were increasing".

However, the fairly slim reference in the report to children and adolescents is not my main source of concern. My main concern is that it makes no mention whatever of the impact on children of the mental health of their parents. This is a hugely important problem today and one about which the Government should be deeply concerned.

The mental health of a parent can have lifelong consequences for his or her child, especially where there is only one parent to whom the child can turn. Perhaps I may give two examples to indicate what I mean. A father with an addiction can often be violent or have unpredictable changes of mood, and that can create insecurity and fear in both the partner and the child. Even the child in the womb can suffer adverse effects on brain development through domestic violence. As the young child grows up, he is seriously affected by the insecurity and uncertainty of attachment. Lack of self-esteem and poor social skills will follow, together with a litany of other problems: dropping out of school; teenage antisocial behaviour; low skills or unemployment; and crime and prison. Of course, I do not wish to exaggerate; they do not arise in every case, but major difficulties are created in a child's development if he grows up in a violent family without the love that he needs.

My second example concerns a mother who suffers from depression due to clinical or postnatal depression, loneliness or a lack of support from family or partner. That depression will also be liable to damage her child, who, again, will lack a secure loving attachment, and that will restrict social and emotional development. Those are but two examples.

Therefore, I ask Her Majesty's Government whether they recognise the importance of parental mental health on young children's emotional and social development and welfare. If so, and in the light of the reduction in antenatal and postnatal services and in the availability of midwives and health visitors in many NHS trusts today, what action do they propose to take to address the damage that can be done to some of the nation's youngest and most vulnerable children by the mental health problems of their parents?

Photo of Baroness Neuberger Baroness Neuberger Liberal Democrat 7:39 pm, 17th October 2007

My Lords, I am delighted to take a small part in this debate and I pay tribute to the extraordinary chairmanship of my noble friend Lady Thomas of Walliswood, whose term as chair of EU Sub-Committee G is soon to be completed. I also pay tribute to the two Clerks to the committee: Barry Werner, its present Clerk, who saw the inquiry to its completion; and Gordon Baker, who set it up and started off the process. I also pay tribute to our special adviser, Professor Martin Knapp. One person who never gets a mention is Melanie Moore, who supplies us with the papers. She is wonderfully efficient and patient with us all when papers do not arrive or we lose them, or when we have a bad day. I pay tribute to her as well.

I wish to cover two main areas. The first is social exclusion and stigma, well covered in the report, which demonstrates that some people with mental health problems suffer from extreme social exclusion and, indeed, that a growing number are in prison. The report says:

"Some people with mental health problems—indeed it would appear to be a growing number—are in prison. The Mental Disability Advocacy Center suggested that prisoners and people in (long-stay, institutional) social care homes with mental health problems were vulnerable to abuse and mistreatment ... Mind wanted people in prison to be added to the Green Paper's list of marginalised groups that should be targeted in the strategy. They cited the Social Exclusion Unit's estimate in 2002"— we do not have a more recent estimate, unless the Minister can provide us with one—

"that 72 per cent of male prisoners and 70 per cent of female prisoners suffered from two or more mental disorders, proportions that were 14 and 35 times, respectively, the levels found in the general population".

I also draw attention to the work that the Sainsbury Centre for Mental Health is doing in the area of mental health in prisons. I declare an interest as an adviser to the trustees of the centre. Most prisoners who have mental health problems still find that they receive little or no help while in prison or on leaving. That includes people with moderate depression and anxiety, those with personality disorders and those with concurrent mental health and substance misuse problems, the commonly referred to dual-diagnosis group.

The other issue that is relevant to this report and to what we are discussing is resettlement. The resettlement experience of prisoners is poor, with most receiving little meaningful help on leaving prison. The position for those with mental health problems, especially those with dual diagnosis, is even worse, as they have even greater vulnerability. That is what we mean by extreme social exclusion. Although most of our evidence referred to the social exclusion experienced by people as a result of their mental health problems, the case was also made—this is worth stating—that social exclusion itself could be a risk factor for poor health, including poor mental health.

The organisation Mind drew our attention to Annexe 7 of the Green Paper, which summarised material from the World Health Organisation identifying key risk factors. These included a variety of things, such as exposure to drugs and alcohol, as I have just mentioned, lack of education, transport and housing, peer rejection, poor social circumstances, and so on. Mind was, therefore, concerned that a medical model of mental health, which it still saw as dominant in many countries, would obscure the social causes and contexts of much mental distress. It is important to think about that.

The noble Lord, Lord Northbourne, was absolutely right to draw our attention to the effect on children of parental mental ill health. Of course, part of that much broader social context of mental ill health reflects very heavily on children. The noble Baroness, Lady Howarth, will talk about that.

Meanwhile, Rethink noted the close link between unemployment and mental health problems. It referred to the Social Exclusion Unit report that social isolation was an important risk factor for deteriorating mental health and suicide and, shockingly, that two-thirds of men under the age of 35 with mental health problems who died in the UK by suicide were unemployed. This is terrifying stuff. When it came on to the matter of stigma, things got even worse. I quote from paragraphs 164 to 167:

"Professor Graham Thornicroft of King's College London, Institute of Psychiatry, suggested an agenda for mental health policy. His starting point was the widespread discrimination experienced by people with mental health problems 'at home, at work, in personal life, in social activities, in healthcare, and in the media'. He made the distinction between ignorance (the problem of knowledge), prejudice (the problem of attitudes) and discrimination (the problem of behaviour). Stigma stemmed from these three: from the widespread misunderstanding of mental health; from the fear, anxiety and avoidance of the general public and of people with mental health problems ('self-stigma' because they anticipated rejection and discrimination) ... In its Green Paper the Commission recognised these problems, stating that people with mental health problems met fear and prejudice from others, often based on misconceptions. They also recognised that stigma increased personal suffering and social exclusion, and could impede access to housing and employment.

Dr Marcus Roberts of Mind noted ... 'it is stigma that keeps people out of work, it is stigma that stops them approaching services when they need help, and it is stigma that keeps people isolated because they do not integrate into their community, and therefore it perpetuates in a vicious circle [the] wider causes of mental health' ... Many others reiterated these concerns to us", time and time again. Paragraph 168 states:

"The Open Society argued that tackling stigma was essential if Member States were to make progress in pursuing the first three priorities identified by the Green Paper, i.e. promoting mental health; preventative action; and improving quality of life through social inclusion and protection of rights and dignity".

It is for that reason that I bring us back to a conversation that has been ongoing in this House for some time now. In 2004, the Council of Europe agreed Recommendation 2004/22 concerning the protection of human rights and dignity of people with mental disorders. The aim of that recommendation was to consider what common action at a European level will promote better protection of the human rights and dignity of persons with mental disorders. The British Government signed the recommendation but, at the last minute, added a qualification note reserving to the Government the right to comply or not with the recommendation as a whole, which one might argue made questionable why they had signed it at all.

The Government stated in an answer to a Parliamentary Question from Lynne Jones about this decision:

"The Government fully supports the majority of the Recommendation ... We had no wish to oppose its adoption. However, because we are in the process of revising important aspects of the legislation in England and Wales on mental health and mental capacity, we were not in a position to identify definitively whether there were specific points in the Recommendation on which we might wish to reserve our right not to comply".—[Hansard, Commons, 20/10/04; col. 796W.]

At that point, the implication was that the Government did not feel able to sign up fully to the recommendation while the mental health legislation was going through, even though other countries in the Council of Europe had done so. But, of course, the mental health legislation has now gone through Parliament, as Members of this House will be only too well aware, after many hours spent debating it. So before the Summer Recess my noble friend Lady Thomas of Winchester asked Her Majesty's Government:

"What are their reasons for tabling qualification (Note 1) made to the Committee Ministers' Recommendation".

The reply that she received from the Parliamentary Under-Secretary of State, the noble Lord, Lord Darzi of Denham, was that the Government had no particular objection. He said:

"Now that the Mental Health Act 2007 has received Royal Assent, there is an opportunity to review that reservation".—[Official Report, 1/10/07; col. WA173.]

Given that Written Answer, what plans do the Government have to review the reservation?

The Royal College of Psychiatrists has been keeping a watching brief on this and argues that, given that the principal objection to signing with a reservation has gone, surely this is the time to make a statement that the UK Government are dedicated to protecting the human rights and dignity of persons with mental disorder by removing that qualification. Indeed, everything in this report from the EU Sub-Committee G would lead one to that conclusion. I ask the Minister whether she could tell me when we might see progress. What other plans do the Government have to deal with stigma suffered by those with mental illness, given the European Commission's great welcome for the report and the Government's assertion in their response to the report that they are already doing a considerable amount through the Shift campaign, although they recognise that public attitudes to mental illness can still reflect a degree of fear?

The Shift campaign has a lamentably small budget, as the report makes clear. It is only one-twentieth the size of the budget for the successful anti-stigma campaign in New Zealand, which has significantly changed attitudes. Expenditure on anti-discrimination work per head in New Zealand was 34 pence per head, compared with 13 pence in Scotland and a mere 1.44 pence in England. It would be good to hear from the Minister what the Government propose to do to increase what is spent and to guarantee long-term funding for such anti-discrimination work, particularly given that John Bowis, Member of the European Parliament, in his superb evidence to the EU sub-committee, identified defeating stigma as the most important area in the EU document. I look forward to hearing from the Minister what the Government intend to do to improve this situation.

Photo of Baroness Howarth of Breckland Baroness Howarth of Breckland Crossbench 7:49 pm, 17th October 2007

My Lords, I join my colleagues in thanking those who supported us through this campaign. I am not going to name them all, but I pay particular tribute to the noble Baroness, Lady Thomas, for her chairmanship. I felt that it was a great privilege to be a member of the committee. I hope that I will speak about the things that people are indicating that they think I will be speaking about. I will certainly talk about what I know.

During my time on the committee, I have learnt some weird and wonderful things, not least the language—by which I mean the language in English. When we are able to understand what the directives are telling us, they often have clear implications not only for Europe, but often for the legislation going through this House at any point in time. The noble Baroness, Lady Thomas, pointed out that we struggled at the beginning of this inquiry to understand how both we and Europe could add value to mental health thinking across the whole spectrum. I hope that, in some of the things that I shall say, the Minister will agree that value has been added and that Europe may well add even more as we move forward.

To emphasise this link between domestic legislation and what can be shared, I should say that this House was considering the Mental Health Bill, as it then was, when we were discussing this Green Paper. The discussion and arguments that surrounded that Bill, before it became an Act, will be fresh in the minds of many here today. It is interesting, given some of the controversial discussion, that the UK is considered by the Commission to be one of the best performers in this area of social care, with much to offer the rest of Europe. We need to maintain and continuously improve that position while sharing our expertise, and be prepared to learn from other nations in order to keep ahead of the game in the area of social intervention.

The consensus among organisations in the UK representing both providers and service users is that front-line services for the treatment of mental health problems should primarily be based in the community, although hospitals still need to play an important part as specialist providers. Colleagues who, like me, were involved in the closure of large mental hospitals in the 1970s will remember that the resettlement of people displaced from those establishments was not an orderly affair; it was about asset stripping. The funding for community services did not equal that released from the closures and the support and care of the long-term mentally ill for many years became the poor relation in social care services. The committee heard during the inquiry that many EU countries developing community-based services feared that the same would happen as they moved from one system to another. As the UK is now commended for its standard of community care, this is surely one area where experience can be shared across the EU to the benefit of service users without other countries having to repeat the pain and mistakes made here.

This was just one area where the committee supported the Commission's proposals for sharing good practice across the EU and, indeed, more broadly. We were particularly impressed by examples of proven effectiveness and would encourage the Commission in its plan to provide a platform through which sharing can take place. I am sure that the Minister will confirm that the Government, while acknowledging that member states must be responsible for their own health services, are equally encouraging of this way forward.

To the noble Lord, Lord Northbourne, I say that children had barely a mention in the initial Green Paper. It is to the credit of the committee that there is a little more in the present report and that these issues are being further addressed in both the government response and, we hope, in the new Green Paper. However, that is exactly the position in which we found ourselves with the original Mental Health Bill on the Floor of this House. It was only after much debate that the Government included a measure, supported by the Convenor of the Cross-Bench Peers, to ensure that children should no longer be detained inappropriately in adult institutions.

We know from the evidence of the Open Society Mental Health Initiative to the committee that, across much of Europe, many young people with mental disabilities are accommodated in large orphanages or are held in prisons or young offender institutions. As the UK action might be an excellent example to share with Europe, especially with some of the newer members that are struggling to develop alternative services for children, can the Minister say what progress has been made in completing the implementation of this measure in the UK? We should show a lead in the care of the mental health of our children and stop the inappropriate placements so well documented by both YoungMinds and the Children's Commissioner.

Mental health problems thrive where there is social exclusion, loneliness, poverty and, as the noble Baroness said in great detail, stigma. In understanding mental illness, we must have a context of mental health but be clear about the differences, just as the Commission now recognises the difference between learning difficulty and mental illness. This was clearly an achievement for the committee, as the difference was acknowledged both by the Commission and in the Government's response following our report. The noble Lord, Lord Rix, who is unable to join this debate, has asked me to express his thanks and that of Mencap for this basic clarification, which might have real influence in those countries where those with learning difficulties are still treated as mentally ill, whether or not they have a mental illness.

The answer to much of this and similar issues is not to rely entirely on a medical model of mental illness—such a model dominates most EU countries and can obscure the social causes and context of mental distress—but to recognise the many factors contributing to mental ill health. The noble Lord, Lord Northbourne, said most eloquently how much we should look at the whole family and, indeed, carers and parenting. I quote from the report:

"We believe that a 'public health' approach for addressing the promotion and prevention of mental health issues is to be encouraged, recognising the multiple influences on the mental health of populations, from outside as well as from within the mental health system as conventionally defined".

As these populations clearly include our European neighbours, does the Minister agree with the committee about the importance of working together with Europe in this important area?

Photo of Lord Trefgarne Lord Trefgarne Conservative 7:57 pm, 17th October 2007

My Lords, with your permission I will make a brief intervention. Like other noble Lords who have spoken, I, too, have the honour to be a member of this committee and pay tribute to the noble Baroness, Lady Thomas, our chairman, who will shortly be standing down; and, indeed, to our officials, Mr Gordon Baker, Mr Barry Werner and Melanie Moore.

One of the hallmarks of our committee is the acres of rainforest we destroy every week in the mass of paper we consider and pass judgment on. This report was no exception. Twenty-five years ago, I was made a very junior Minister at the Department of Health and Social Security, as it was then—a mega-department if ever there was one. I was made responsible for mental health and mental handicap under the wise and distinguished leadership of my noble friend Lord Fowler, who was then the Secretary of State. My first assignment in that post was to visit a mental hospital near Leavesden in north London—long since closed, I am happy to say—which had been opened in 1910. In that year, 1982, I met a lady who had gone in on the day it was opened: she had been there for 72 years. She was only sent there because she was an unmarried mother. Apparently, in the years before the First World War, unmarried mothers were called "moral defectives" and sent to institutions like that.

It was therefore with some distress that I read the other day that there is lady in a National Health mental hospital who had likewise been in one of these establishments for 80 years. I hope the Minister can assure us that these matters are kept under review. I know it is not straightforward because if you find a lady who has been in that long she will almost certainly have nowhere to go, but the idea that somebody should be retained in one of these places for no good reason causes me considerable distress, and I am certain it would have caused my colleagues and me difficulty, if we had addressed our minds particularly to that issue. I hope the Minister can reassure me on that point at least. That said, I commend the report of the Select Committee to your Lordships and hope that it will find modest approval.

Photo of Lord McColl of Dulwich Lord McColl of Dulwich Shadow Minister, Health 8:00 pm, 17th October 2007

My Lords, I, too, thank the noble Baroness, Lady Thomas of Walliswood, for initiating this debate and for doing such a great job in chairing the committee. I shall draw attention to two aspects of the recently discussed Mental Health Bill that are relevant to mental health generally. We managed to persuade the Government to put in the Bill a commitment to include in guidance a set of principles for the conduct of good mental health treatment. The whole mental health community saw that as an extremely positive step. The Government were also persuaded to insert an amendment on age-appropriate treatment for children. That was regarded as a very important symbolic move and was also important in a practical clinical sense. These changes created a significant and useful piece of legislation because the Bill as originally presented purported to deal only with locking up people who were seen to be a danger to themselves or others. It was therefore important to widen the Bill in those two important aspects. The Government were wise and farsighted to agree to them. What are they doing to spread this message throughout the European Union?

The World Health Organisation has stated that mental health is not merely the absence of disease but rather a condition of complete mental well-being in which individuals recognise their abilities, can cope with the normal stresses of life, work productively and make a real contribution to their communities.

There has been a great deal of discussion about the vernacular. The Samaritans use the term "emotional health" as a less threatening and less medical term. It is important to emphasise, as have noble Lords, that mental health is not just a medical issue but is also a social and economic one and that it is not the sole preserve of health ministries. The Scottish Association for Mental Health has recommended the use of the term "mental health problems" rather than "mental illness" or "mental disorder" as it is less stigmatising. The commission has drawn attention to the advantages of not getting too mired in medical models of mental health. The report quite rightly stated that it is wrong to group together learning disability and mental health problems because the two conditions are quite separate. A person with a learning disability may or many not suffer from a mental health problem. It recommended that the commission should launch an action programme to address concerns about people with learning difficulties throughout Europe and to look into how they are supported and the quality of their lives.

The report drew attention to the fact that in Europe there is increasing absenteeism, early retirement and reduced performance of people at work due to mental health problems. For instance, in France, in the year 2000, 32 million lost working days were due to depression; in Sweden, a quarter of all cases of long-term sickness were due to mental health problems; and in Germany, they were the cause of a 74 per cent increase in people on long-term sick leave between 1995 and 2002.

The report draws attention to the impact of mental health problems on families. It looked at the families of people with schizophrenia in five European cities. Principal family carers spent an average of six to nine hours daily supporting their relatives. There are 1.5 million carers of people with mental health difficulties in the UK, so it is crucial that we support them. These carers themselves become twice as prone to develop mental health problems when involved in giving substantial care. There are also severe economic impacts on families, many of whom have to give up work to provide care. My noble friend Lady Thatcher, when she was Prime Minister, was always very concerned about the question of respite care, recognising what an enormous debt we owe to carers who save the nation billions of pounds.

Noble Lords referred to the huge problem of mental health in the prison population. I should mention that there are volunteers who do valuable work in prisons, trying to give hope and purpose to prisoners' lives, which is likely to prevent mental health problems and reduce the incidence of suicide. In November 2000, the number of prison inmates was 64,000; this month it stands at more than 81,000. The BMA has drawn attention to the acute pressures on health services, as have people within the prison healthcare system. A prison doctor recently reported that:

"Prison healthcare services do not have the staff, infrastructure or budget to cope with the needs of the rising prison population. Unacceptable delays in assessing and treating prisoners are now commonplace, while specialist services designed to deal with mental health and drug addiction problems are badly stretched to the point of becoming ineffective—a disastrous situation considering how endemic these conditions are within the prison population".

The WHO report also draws attention to the need to encourage the consumption of healthy products and reduce the intake of harmful products. It might have stressed the obvious poison—cannabis—which is a cause of schizophrenia. The emphasis should not simply be on reducing the intake of cannabis but on stopping it, and on never starting it in the first place. In retrospect, it is a pity that the Government downgraded the seriousness of the drug to class C. However, in medicine we talk about the retrospectascope being an interesting instrument. We all make mistakes, but it is a good thing to put them right.

The Conservative Party would like to see a much stronger emphasis on public health, of which mental health is an important part. We want mental health improvements to be a key priority for the NHS. We would like a new structure for public health enabling local directors, jointly appointed by PCTs and local authorities, to determine how best to spend the resources. They would be better placed to make effective interventions across the health, local government, education and social housing sectors. Independent, ring-fenced budgets should be introduced because the current system of budgets for public health interventions being largely channelled through PCTs means that any shortage of money in the PCT results in a raid on the budget. These budgets should be taken away from the PCTs and spent through a new public health structure, rather than through traditional NHS bodies which tend to focus more on acute and community services.

Noble Lords have emphasised the importance of employment for those affected by mental illness. That reminds me of Guy's Hospital during the war when everyone had to take a hand in some of the more mundane occupations, such as rolling bandages—bandages were washed in those days after they were used and had to be rolled. Surprise, surprise, the consultants did not prove to be very efficient in that occupation, but the patients in the psychiatric wing were far and away the most effective and productive.

Another area the report highlights is the need to address mental health concerns among the growing number of old people in the European Union. This has already been mentioned. It correctly encourages national Governments to focus on the identification, prevention and treatment of mental health problems in older people. This is very important, as Age Concern figures show that one in four older people have symptoms of depression that warrant intervention. It also reports that dementia costs the health and social care economy more than cancer, heart disease and stokes combined.

As far as concerns tackling discrimination and stigma for those with mental health issues, it is important to emphasise that one-third of the population in this country suffer from mental illness during their lifetime and, crucially, that mainly there is a good outcome of treatment and they are rarely associated with violence. It is the fear of violence that stops people empathising with mental health patients. The violence that they find the most disturbing is, for instance, when a patient with schizophrenia becomes so paranoid that he takes an axe to hack down the walls of his house to find the microphones that he is convinced are there. That actually happened to a 30 year-old patient, but his treatment was successful and there has been no further trouble over the ensuing 40 years. I was going to quote Professor Graham Thornicroft's agenda for mental health policy, but the noble Baroness, Lady Neuberger, has done that. I was going to point out that he was an extremely good medical student at Guy's Hospital, but I will not.

The report stresses that we must improve public understanding to counter negative attitudes. That can be done when the public begin to understand the causes, characteristics and impact on mental health problems. This is sometimes referred to as improving mental health literacy. The report also suggests that countries should be required to begin a reporting system where they monitor their success in enabling the employment of those with mental health problems. Perhaps there should be a statutory percentage of people so employed, as we used to have for those with physical disabilities—I believe that there used to be an obligation to employ four percent within the workforce.

There is still a tendency today to have jokes about mental illness, often at the expense of psychiatric patients. There may be many reasons for this, not least of which is the fear of mental illness. On radio and television there is still a tendency to ridicule the whole subject and those who are affected. More needs to be done to improve this situation, and people really should avoid some of these unpleasant descriptions. No one would dream of making inappropriate jokes about patients with heart failure, osteoarthritis or other physical conditions. Change is possible however, as it was not so long ago that jokes about disabled people were made without compunction. That situation has certainly improved considerably.

The Government have done a deal to improve mental health in the UK, and the European Union would do well to ensure that these improvements are encouraged throughout its area.

Photo of Baroness Royall of Blaisdon Baroness Royall of Blaisdon Government Whip 8:14 pm, 17th October 2007

My Lords, I, too, congratulate the noble Baroness, Lady Thomas, and her committee on their truly excellent report. I am very sorry that this will be the last time that we shall hear from the noble Baroness in her role as chair of the committee. She has done a superb job, and I thank her on behalf of the Government.

The depth of the report, its grasp of some very complex issues and the quality of its analysis show clearly just how valuable the committee's work is, and, indeed, how much the Government appreciate it. Its work is held in high regard, as noble Lords will know, throughout the European Union. We are very proud of what it does. Ministers have, of course, responded formally in writing so I will not repeat all the detail of their response. But I am grateful for the opportunity to discuss the Government's approach.

Constructive and rational debate on mental health is important, especially because it is a subject that many find difficult to talk about. Even here, in the 21st century, mental illness can still too often provoke embarrassment, even shame and sometimes jokes. It also has consequences and can be exacerbated by the reactions of family, friends and society who have misconceptions about mental illness. This is a direct consequence of the discrimination and stigma that people are often subject to, both directly and indirectly, by individuals who do not understand and institutions that do not care.

We must believe that all this can change, but it needs to change more quickly. We agree with the committee that the more open we are, the quicker we will dispel ignorance and enlighten attitudes. After all, as the noble Lord, Lord McColl, said, it is not as though mental illness is a rarity and something that only a few of us will ever experience. As the committee noted, it is remarkably commonplace. In the UK one person in six suffers symptoms at any one time. A quarter of GP consultations involve a mental disorder. A million people are off work and claiming benefits because of their mental illness.

The impact on individuals, families and society as a whole is immense. So there is real truth in the observation that we all have a mental health problem. That is why we welcomed, first, the World Health Organisation's action plan for mental health in Europe, also known as the Helsinki declaration, and then the European Commission Green Paper that the committee has scrutinised so expertly.

I shall spend a few minutes describing the Government's commitment to improving mental healthcare and promoting good mental health. This is not complacency or an attempt to score points; it is simply that the prevailing conditions in any member state are bound to influence its relationship with a European Union strategy.

The Government's commitment to mental health as one of their top clinical priorities has, with the skill and dedication of front-line staff, helped to deliver some very positive changes. Many have already been mentioned this evening and the committee was kind enough to acknowledge some of them in its report.

The blueprint is the National Service Framework for Mental Health, a 10-year plan published in 1999. I think it is fair to say that the NSF enjoyed widest support then, and that it still does today. It has guided us through what is arguably a transformation in mental healthcare in this country. There are many achievements, but I cite just a few pertinent facts to illustrate my point. Compared with 1997, we now have in post 50 per cent more consultant psychiatrists and 20 per cent more mental health nurses. There are more than 700 new teams working in communities to provide mental healthcare in new ways, including assertive outreach, early intervention and crisis resolution.

Of course it is not enough. In the past five years, planned NHS and local authority expenditure on mental health services has risen in real terms by 31 per cent. According to the European Commission, UK spending on mental health as a proportion of either total health expenditure or GDP is now among the highest in the European Union. We also have a suicide prevention strategy that has seen the rate in England drop to its lowest recorded level, and, according to the Green Paper, to one of the lowest in Europe.

The committee took evidence from Mr Matt Muijen, the World Health Organisation's European adviser on mental health. In the past he has been extremely generous in his assessment of services in the UK, but his praise is far from unqualified. We too have much to learn from best practice in other member states; for example, the work done in Finland to raise awareness and understanding of severe mental illness.

The noble Lord, Lord McColl, asked what we are doing to spread best practice now. We discussed these issues under the auspices of the WHO. Clearly the approach suggested by the European Commission would be an excellent way of spreading and facilitating exchange of best practice even further. That is precisely why we welcome it. We rather like the platform approach under which the Commission would facilitate discussions of stakeholders from throughout the European Union.

We know that there are still significant deficiencies in services and that our job is not yet done. We need, for example, to offer a wider range of services, in particular by enhancing the availability of psychological therapies. Last week, on World Mental Health Day, the Secretary of State reaffirmed his commitment by announcing a substantial £170 million expansion of these therapies, building on two demonstration projects. The Government will next year roll out psychological therapies to 20 new areas before increasing services to cover the whole country. By 2010-11, 900,000 more people will be treated for depression and anxiety with half likely to be completely cured. All GP practices will have access to psychological therapies as the programme rolls out, and the average waiting time will come down from the current 18 months, which is shameful, to a few weeks. That is good news for hundreds of thousands of people and it is in no small measure due to the efforts and commitment of my noble friend Lord Layard.

The noble Baroness, Lady Howarth, rightly raised the issue of children and young people and mental health. It was also mentioned by the noble Lord, Lord Northbourne. The noble Baroness, Lady Howarth, asked what we had done following the Mental Health Act 2007 to ensure that patients under 18 were not placed on adult psychiatric wards unless that environment was suitable for their age. Section 31 of the Act is not yet in force. Most of the Act's provisions will be implemented from October 2008, but those on age-appropriate environments, and indeed those on advocacy, are likely to follow a little later so that services can develop adequate capacity. We have discussed this timescale with key stakeholders who, although anxious to avoid unnecessary delay, understand and accept that position, I am assured. However, I note the views expressed by the noble Baroness and also the face she has just shown me.

The noble Lord, Lord Northbourne, spoke about children with mentally ill parents. Of course, we recognise the needs of children, especially those who act as carers for parents who suffer from mental health problems. The Government introduced a strategy to support all carers, including the provision of about 100 new carer support workers. We also asked the Mental Health Act Commission and the National Institute for Mental Health in England to consider the particular needs of children whose parents have been admitted to hospital. We look forward to receiving their advice.

The noble Lord might also be interested in the child emotional health and well-being public service agreement, which I happened to look at last night. This PSA would allow us to focus on improving the outcomes that we expect to see in relation to child health and well-being. One of the five indicators will be to monitor developments relating to emotional health and well-being and child and adolescent mental health services. We are taking cross-government action on that specific issue.

Of course, there are still pernicious inequalities in mental health, especially among black and ethnic minority communities. We need and must have more effective responses in those areas, but the response is now being guided by the Delivering race equality in mental healthcare action plan, which is being implemented throughout the country.

The noble Baroness, Lady Neuberger, and other noble Lords raised the difficult issue of mental health services in prisons. We have invested more than £600,000 over three years in mental health awareness training for prison officers and staff. All prisoners are assessed at the point of reception into prison and those at risk of having a mental health problem, or being vulnerable to suicide, are referred for a mental health assessment. Since 2005, nearly £20 million has been invested each year in mental health in-reach services. However, I recognise that very grave problems still persist.

The resettlement of prisoners is especially difficult for prisoners with mental health problems. In Gloucester prison, of which I have some experience, I know that great strides are being made to ensure that prisoners who suffer from mental health problems are resettled as best as possible. Mental health workers within the prison liaise with mental health workers on the outside to try to ensure that there is some joined-up thinking. The noble Lord, Lord McColl, spoke of the important role played by volunteers in prison and I pay tribute to them. He also mentioned cannabis. I am glad to say that the Prime Minister, as noble Lords will know, is reflecting on the reclassification of cannabis.

The noble Lord also spoke about public health. That is one of the issues that my noble friend Lord Darzi will be looking at in his review. Clearly, there must be greater interaction between local government, other bodies and PCTs because they all have some responsibility for public health.

The noble Baroness, Lady Neuberger, also spoke about the fight against stigma and discrimination, which is being taken forward by our Shift campaign. I also thank the Sainsbury Centre for Mental Health for the excellent work that it is doing. Last week the Government relaunched their guidance to line managers on support in the workplace for people with mental health problems, and I noticed a small article in the Guardian today about that. As noble Lords may know, Shift is the Government's five-year programme for taking forward the fight, and we hope it will work closely with the new Moving People campaign.

Moving People is potentially an important development. It is a partnership led by Mind, Rethink, Mental Health Media and the Institute of Psychiatry, funded by £18 million from the Big Lottery Fund and Comic Relief. It aims to reach 30 million people over the next four years, through TV advertising, tackling discrimination and training and education for 10,000 key leaders with the power to influence and change behaviour in key sectors such as the medical and teaching professions. Shift is still important but Moving On is a new initiative.

I also draw noble Lords' attention to an excellent project that I visited in Battersea last week called the Thrive Battersea Garden project. Thrive is an organisation that works with people with disabilities and mental health problems and assists them in learning new skills so that they can be reintroduced into the workforce. That is an excellent project which I commend to noble Lords.

We had no hesitation in signing up to the WHO plan in January 2005. The Helsinki declaration sets out 12 areas for action to increase awareness, reduce stigma, promote social inclusion and protect human rights. We are still fully committed to the plan, and there is a lot of hard work being done to develop policies and services that are consistent with its ambitions.

Later in 2005, we welcomed the European Commission's Green Paper for its potential to support the WHO plan's implementation. Like the committee, we recognise the unique potential of the EU to spread action beyond the traditional boundaries of health and social care into important areas such as employment. Our response to the Commission, which doubled up as our written evidence to the committee, was clear that we backed the idea of an EU mental health strategy, albeit with two provisos. First, the strategy should support the WHO plan, without confusing matters by either adding to it or competing with it. Secondly, the strategy should be flexible enough to accommodate and facilitate individual member states' own local priorities. We are quite firm on those, and we have not detected any resistance to them from the Commission. They are important principles. An EU strategy that fails to dovetail with the WHO plan is a recipe for failure on both fronts.

We also need to remember that member states are starting from very different points and are best placed to decide their own priorities for action within the framework of the WHO plan. The Green Paper itself recognises that member states have exclusive competence for the organisation of health services. States are entitled to expect an EU strategy that offers help in meeting their priorities.

People have strong and sincere feelings about mental health and mental healthcare. It is completely understandable that they should see the production of an EU strategy as a chance to have their particular concerns addressed. But a strategy cannot try to be all things to all people and still be of practical benefit across the continent.

The committee's report recommends that the Commission encourages national governments in certain directions; for example, towards early identification and treatment of illness or better services for children. By and large this is entirely consistent with the Green Paper and with domestic policy. Nevertheless, we expect that encouragement to take the form of, say, the identification and dissemination of helpful good practice rather than attempts to pin down member states en masse to closely defined and uniform priorities.

I understand that the committee may be a little disappointed by our response to its recommendation on principles for mental health policy across Europe. In fact, we feel that there are principles quite strongly implied in the Green Paper and the WHO plan, and that reaching a consensus on anything more explicit or detailed might prove problematic. Nevertheless, we would be happy to consider any proposal that emerges.

The noble Baroness, Lady Thomas, asked about the Government's view on the need for a reporting obligation to monitor how employers are performing or employing people with mental health problems. We would consider any proposal from the EU, but already we have sources of information, including attitude services, that show that a worrying proportion of employers are reluctant to recruit people with mental health problems. The Shift campaign is addressing these directly. We all have a responsibility to do something about the pernicious issues relating to stigma and discrimination.

The noble Baroness, Lady Neuberger, made a vital point on the Government's reservation and the letter from my noble friend Lord Darzi about reviewing our position. I regret that I do not have any information for her today, but I will write to her. It is not quite joined-up thinking at the moment.

The cases that the noble Lord, Lord Trefgarne, cited were distressing, but I assure him that we keep cases under review. The noble Baroness, Lady Howarth, mentioned the noble Lord, Lord Rix, and his pleasure that the committee agreed with him that it would be inappropriate for a strategy to address mental illness and learning disability jointly. The Government fully support that view.

We await the EU's communication on mental health with great interest. I have no idea of what to expect from it or much more of an idea of when to expect it, but I understand that it is unlikely to be before the end of this year, as the noble Baroness said. For the Government, I will say that we hope we can play an active and leading role in taking forward the strategy, and through it the WHO action plan, for the benefit of the many millions of vulnerable people in the UK and the rest of the European Union who suffer from mental health problems.

Photo of Baroness Thomas of Walliswood Baroness Thomas of Walliswood Spokesperson in the Lords, Women and Equality 8:32 pm, 17th October 2007

My Lords, I thank everyone who has taken part in this debate, including the members of the committee, but, more particularly, the noble Lords, Lord Northbourne and Lord McColl, and the Minister who have given us so willingly of their time and expertise. I always think that listening to the noble Lord, Lord McColl, is like hearing the word of wisdom in a very humane voice.

I thank everyone also for their congratulations directed towards me. As I say, I could not have managed any of it without the sustenance of the advice and help of the Clerks. I will include in that, as I forgot to do earlier, Melanie, whom we could not live without as a committee.

On Question, Motion agreed to.