I begin by thanking all your Lordships for the wide-ranging debate. I want to say how much more I learn, listening to the contributions in each of these debates, before I stand up to speak. I thank all noble Lords for their contributions. As the noble Baroness, Lady Merron, says, this debate carries some weight for our understanding that social, mental and physical well-being are equally important. We should not seek to suggest that one takes precedence over another. I also thank the noble Lord, Lord Stevens, for kicking off this debate with his encouraging and not critical amendments; I take them in that spirit.
Following on from that, and before I go to some of the specific amendments, I will just reflect on some of the contributions made thus far. I first thank the noble Lord, Lord Howarth, for raising social prescribing. I know we have discussed this a number of times since I became the Minister, with particular contributions from the noble Baroness, Lady Greengross, on the importance of art and music in helping to unlock the mind and touch the soul.
As has been made clear, social prescribing is a key component of the NHS’s universal personalised care, and I know that, crucially, this can work well for those who are socially isolated or whose well-being is impacted by non-medical issues. The NHS has mechanisms to ensure that social prescribing is embedded across England: for example, the primary care network directed at enhanced services specification outlines that all PCNs must provide access to a social prescribing service.
I also thank the noble Lord, Lord Patel, for raising the importance of the mental health of children and for making sure that we do not forget, even within mental health, that many sections of our society can quite easily be forgotten.
I agree with the right reverend Prelate the Bishop of London: we have come a long way. I remember as a child in the 1970s going to visit my uncle who was a psychiatric nurse at Claybury Hospital and looking at the patients, with the innocence of a child, and thinking, “These people don’t look ill to me.” We have come far since then. I remember the Rampton hospital scandal in the late 1970s, where the patients were treated appallingly, almost not as humans, and with a lack of dignity. The fact that today we are discussing the parity of mental with physical health shows how far we have come as a society.
We also spoke about loneliness and isolation. The noble Baroness, Lady Watkins, and I have had conversations about loneliness and some of the civil society projects that, for example, bring together lonely older people with children from broken homes so that both can benefit and learn from each other. I remember a story that I have mentioned in the past: in one of the projects I visited, a rather old man said, “I lost my wife five years ago and I had almost given up on life. The fact that I am now working with children from broken families and am almost being a mentor to them gives me a purpose to live—a reason to get up in the morning. I have no longer given up on life.” There are so many of these civil society projects, and no matter how we legislate, sometimes those local projects get to the nub of the problem in their local communities.
I have to pay attention when not only two former NHS chief executive officers but the former Chief Nursing Officer speak in the debate. The noble Lord, Lord Crisp, talked about the focus on outcomes, not inputs and how it is important to make sure that we are not gaming the system, mentioning mental illness and mental health but not doing anything effective about it.
Autism was mentioned by the noble Lord, Lord Warner, a former Health Minister. We are fully committed to improving access to and provision of health and care services for autistic people and people with a learning disability. I know that we have had at least one debate on the treatment of patients with autism and sometimes the terrible conditions they experience. That just shows how important this is.
I am trying to say that in many ways that the Government are absolutely committed to supporting everyone’s mental health and well-being and to ensuring that the right support is in place for all who need it. I therefore welcome the amendments which look to ensure parity of esteem across physical and mental health. I assure noble Lords that we support the sentiments behind these amendments and take mental health seriously.
Indeed, one of the considerations in weighing up the many arguments for further measures in response to Covid—from those who were asking for lockdown, for example—is that we also had to recognise that there was a mental health impact to lockdown. As a Government, we had to look not only at the societal and economic impacts but the mental health impacts within health considerations.
On the amendments, I will first address those tabled by the noble Baroness, Lady Hollins—I add my voice to those of the many noble Lords who have paid tribute to her work over many years in promoting this issue and ensuring that we take it seriously. I also pay tribute to the noble Baroness, Lady Walmsley, for making sure that we are informed about this. These amendments would explicitly reference both mental and physical health and illness in certain provisions of the Bill. I understand that the intention is to ensure that due attention is given to both “mental and physical health” and “mental and physical illness”. Indeed, you cannot separate mental and physical illness, as the noble Baroness, Lady Jones, said. We have moved way beyond “Pull yourself together, man” or a stiff upper lip attitude. We see how mental health plays a role, for example, in terrorism, with those who are recruited to be terrorists, or in those with eating disorders, or the number of people in prison who suffer from mental health issues. It is important that we fully recognise that.
That is why, in line with the World Health Organization guidelines, the current references in the Bill to “illness” and “health” already cover mental and physical health. Therefore, while we agree with the principle behind these amendments, we do not think they are necessary. In fact, they could possibly be counterproductive as they could impact the interpretation of those terms in other pieces of legislation.
For example, Amendment 58 inserts “physical and mental” before illness within the proposed Section 14Z34 of the National Health Service Act 2006. However, Section 275 of that Act, which is an interpretation section, defines illness to include both mental and physical illness. That definition flows through into the references to illness in the National Health Service Act 2006 and will include the clauses this Bill inserts into that Act.
In one of my previous careers, I was the head of research at an economic think tank, and I was always fascinated by the unintended consequences that can follow good intentions. One of the unintended consequences we have to be careful of is that the amendments could risk creating discrepancies within other pieces of legislation where there are not explicit references to physical and mental health but where health is currently considered to include both elements implicitly. It could be interpreted that where mental health is not mentioned in those other pieces of legislation, those who have to abide by that do not give it due concern because it is not explicitly mentioned and therefore will do so only where it is explicitly mentioned. Of course, we could go through the statute book and make sure that we tried to amend all that legislation, but I wanted to reassure noble Lords that when we look at health, in terms of the World Health Organization guidelines, that includes both mental and physical health.
For clarity, NHS England will publish statutory and non-statutory guidance to ensure that NHS bodies, including integrated care boards, are clear about their responsibilities for both mental and physical health, echoing the Secretary of State’s duty in Section 1(1) of the National Health Service Act 2006.
On Amendment 99, in the name of the noble Baroness, Lady Hollins, I welcome her interest in ensuring parity again and to reduce inequalities and improve quality, access and outcomes for patients. Integrated care boards must already have regard to the need to reduce inequalities both in access and outcomes for patients under the proposed Section 14Z35 of the National Health Service Act 2006. There are also duties on NHS England, in Section 13E of the 2006 Act, and on ICBs, in new Section 14Z34, to act with a view to securing continuous improvement in the quality of services, including the outcomes that are achieved from the provision of these services which apply to both mental health and physical health services.
The duties on inequalities and improving quality of services must form part of the forward plan the ICBs develop with their partner trusts and foundation trusts in their annual report to NHS England. In exercising their commissioning functions under the proposed new Sections 3 and 3A of the National Health Service Act 2006, ICBs must act consistently with the Secretary of State’s duty to promote a comprehensive health service in England, to improve mental as well as physical health. This also applies to securing improvement in the prevention, diagnosis and treatment of physical and mental illness. ICBs, like clinical commissioning groups before them, will be expected to report on how they have discharged their commissioning functions and will be assessed by NHS England. Furthermore, both have duties to promote and have regard to the NHS constitution, which explicitly recognises parity of esteem.
Amendment 138 in the name of my noble friend Lady McIntosh would require an ICB to report on assessing and meeting parity of physical and mental health outcomes. I hope I can assure her that the reporting and accountability arrangements we already have in place fully meet this need. By virtue of Section 1(1) of the National Health Service Act 2006, the Secretary of State has a duty to promote a comprehensive health service in England designed to secure improvement in the physical and mental health of the people of England and once again in the prevention, diagnosis and treatment of physical and mental illness.
In line with this duty, the Secretary of State, through the mandate to NHS England for 2021-22, has set an expectation that the NHS will seek to treat mental health with the same urgency as physical health. The Secretary of State also has a legal duty to keep progress in meeting mandate objectives under review. NHS England and NHS Improvement regularly report on the agreed metrics for the Government’s review. They also have strong governance mechanisms in place to monitor both physical and mental health spend and service delivery. Furthermore, considerable data is already published, including via the NHS mental health dashboard.
It is also important to note that a direct comparison between mental health and physical health services through standardised measures can be difficult and sometimes of limited value, as there are some key differences in how and when patients need to access them. However, while these differences must be recognised, and measured accordingly, as I have already outlined I strongly agree that they should be treated with equal seriousness and focus to ensure that the best care is provided, regardless of the nature of the health condition. To introduce a further reporting mechanism on ICBs and the Secretary of State would increase the bureaucratic burden, as the measures mentioned are a rudimentary measure of treatment numbers and not a true measure of parity of esteem.
Amendment 263, also tabled by my noble friend Lady McIntosh, would require the Secretary of State to lay before Parliament a report on how funding to NHS England has supported improvements in mental health illnesses. Over recent years, funding for mental health services has increased. Across local CCGs—including learning disabilities and dementia—and NHS England specialised commissioning, it has reached £14.3 billion in 2020-21, up from £13.2 billion in 2019-20. Further to this, under the NHS long-term plan, mental health services are set to continue to receive a growing share of the NHS budget, with funding to grow by at least £2.3 billion by 2023-24.
As I have set out, the Secretary of State already has a duty to promote a comprehensive health service that considers physical and mental health. I reiterate that, through the mandate to NHS England, it must seek to treat mental health with the same urgency as physical health. The Secretary of State has a legal duty to ensure this. I hope that this will reassure noble Lords somewhat that we take this seriously.
Let me conclude by discussing the amendments tabled by the noble Lord, Lord Stevens, and the noble Baronesses, Lady Hollins, Lady Merron and Lady Tyler, relating to the mental health investment standard. Amendment 5 would require the Government to state in the mandate to NHS England whether it must ensure that expenditure on mental health services increases as a proportion of overall NHS revenue expenditure in the period covered by the mandate. I understand the concern that there should be appropriate clarity and transparency in our expectations in respect of mental health funding. However, I believe that this already exists: a mental health investment standard is in place that expects CCGs, and in future ICBs, to ensure that their spending on mental health grows at least in line with the growth in their overall funding allocations. Performance against the mental health investment standard is monitored via the mental health dashboard, which NHS England publishes quarterly and will continue to do so. The mental health dashboard also brings together key data from across mental health services to measure the performance of the NHS in delivering the long-term plan for mental health. I can confirm that, in 2020-21, all CCGs met the standard.
Amendment 12 would require NHS England to produce and lay a report before Parliament disclosing whether, during the previous financial year, funding for mental health services had grown as a share of total NHS revenue expenditure. Amendment 136 would also require each ICB to disclose in its annual report whether, during the previous year, its funding for mental health services grew as a share of its overall revenue expenditure. We fully support the sentiment of increased focus on mental health spending, and I pay tribute to the work of noble Lords across your Lordships’ House in driving change. However, once again I hope I can assure them that the reporting and accountability arrangements we have in place already ensure that mental health investment is a priority for this Government and NHS England, and will be for ICBs in the future.
First, considerable data is already published, as I have mentioned, including on mental health spending. We are concerned that to introduce a further financial reporting mechanism on NHS England or ICBs would be unnecessary, as mechanisms for tracking growth in funding already exist through the mental health dashboard. To strengthen this reporting, NHS England and NHS Improvement required CCGs to commission and publish an independent review of their reported spend against the mental health investment standard in 2018-19 and 2019-20. Due to Covid pressures in the last year, that will not be reviewed. However, NHS England and NHS Improvement will again require CCGs, and in future ICBs, to publish independent reviews for 2021-22.
Having said all that, I have heard the passion and strength of feeling from noble Lords across the House. I want to reassure all noble Lords that I will continue to reflect carefully on the specific points raised in the amendments and in the debate today. I would be happy to meet noble Lords to discuss their ideas and proposals further. I hope that we can find some agreement. I thank your Lordships for the thoughtful debate on this important subject. I hope I have reassured noble Lords that this Government are committed to delivering parity of esteem between physical and mental health. In our conversations between this stage and Report, I hope that we can seek to reduce that gap in understanding. For these reasons, I ask noble Lords to consider withdrawing or not pressing their amendments.