My Lords, it is a great pleasure to wind up for the Opposition tonight and congratulate the noble Lord, Lord Alderdice, on what can be described only as a powerful tour de force. It was a fascinating insight into parity of esteem, as he saw it, in Northern Ireland more generally, which set the context for our debate. Almost all noble Lords have agreed with his proposition that, despite any number of pronouncements, policies and changes in the law, mental health continues to be a Cinderella service. Certainly, my impression of mental health services is that, although they came as part of the health service in 1948, although in the original structures they had their own hospital management committees, which were brought into area health authorities and then district health authorities—and then there was the development of NHS trusts and foundation trusts—and although they were in some cases integrated with those organisations and in some cases were not, they remained invisible throughout. It is a service that continues to be invisible when it comes to the key policy decisions that the Government, NHS England and the regulators make on the health service.
From a managerial point of view it is my impression that, once you become a manager in a mental health service, you stay a manager there—you do not move over. You are not perceived to have the qualities needed to become a leader in a more acute trust. If you look at the NHS people seconded into the department, NHS England or the regulators, you can see how few of them are experienced in mental health services. The noble Lord, Lord Lansley, suggested that this was rather underpinned by the financial system of mental health services whereby, because there is no tariff-based system, clinical commissioning groups tend to negotiate around the tariff and then what is left goes under block contracts to mental and community health services. This puts them at a disadvantage.
Although structures are not important, there is an issue in relation to both the culture and some of the structural issues which seems to account for the lack of focus on and priority for mental health services. Yet my experience when I chaired an acute NHS foundation trust was that many of the challenges we faced were because of the lack of proper support for patients with mental health problems. In any emergency department there will be a huge number of people with these issues. Unless there are properly based mental health services, working side by side with the acute trust, you end up with people inappropriately cared for in inappropriate places, with their outcomes often getting worse and worse.
The noble Baroness, Lady Hollins, asked the Minister a very good question about the sustainability and transformation plans. She thought that the department should not sign off STPs unless it was satisfied that the principles of parity of esteem were fully embraced within them. That is a very good suggestion which I hope the noble Baroness will agree to consider. I have looked at the names of the leaders of the 44 sustainability and transformation plans. They are clearly eminent people, many of whom I know, so there is no doubt that NHS England has appointed people of high calibre. However, they are mainly chief executives of acute trusts, clinical commissioning groups and, in one or two cases, local authorities—particularly Birmingham and Manchester. Why is this? Why have we not turned to mental health chief executives to lead some of these STPs? In my experience, mental health services often know a lot about the system because their clients impact on so many aspects of the service. If we want to make a real, visible indication that mental health services are important, we should look for leaders from mental health services to lead the sustainability and transformation plans. Even if that does not happen, I hope that both NHS England and the Department of Health will ensure that legal requirements for parity of esteem are applied before they are signed off. More than that I hope it is recognised that, unless you put mental health right at the heart of these plans, the ambitions in them are very unlikely to be realised.
I will briefly come to the question of finance. We know that the Government have ordered the NHS to put more money into mental health services. We have heard from noble Lords about the commitment for £1 billion more for mental health by 2020-21. We also heard from the noble Lord, Lord Prior, only last week, that the spend on mental health in 2015-16 is up by 8.4% on the previous year. He said that,
“there is clear evidence that the money that we have been talking about is getting through”.—[
Yet most noble Lords who have spoken would say that they disagree that the money is getting through to the front line. I do not know whether the Minister has seen the recent work by the Royal College of Psychiatrists on mental health services for children and adolescents. It points out that 52 CCGs in England are allocating less than 5% of their total mental health budgets to services for children and young people. We know of the horrendous problem of young people having to be sent to places hundreds of miles away from their homes because of a lack of facilities. We have also heard, from other noble Lords, that the money simply does not seem to be getting through to other mental health services. Is the noble Baroness assured of the accuracy of the returns made by the NHS to her department on the sharing out of the mental health budget, because there is a suspicion that there has been a rebadging of existing programmes to massage the figures to make it look as though mental health spending is up when the clear experience on the front line is that services are being squeezed and squeezed?
I do not doubt Ministers’ good intents in regard to mental health and ensuring that parity of esteem is achieved. However, the reality is that on the front line mental health services continue to be discriminated against and services are under great threat. There is great concern that in the major changes we are going to see in the health service in the next two or three years as a result of the sustainability and transformation plans, mental health, far from being at the core of the changes, will once again be treated as the neglected hidden Cinderella service. I hope that the noble Baroness can prove us wrong.