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No-one should wait longer than 13 weeks for mental health treatment

February 8, 2008 12:00 AM
By Nick Clegg:

Thank you all for being here and thanks also to the Guardian Public Services Summit for their kind invitation to speak today. As you know, the theme of this year's Summit is how relationships are altering, and dynamics are changing, in the delivery of public services. Today's public service providers are returning to that theme again and again.

We shouldn't be surprised by that. Our schools, universities, and hospitals are facing greater challenges than ever before. The frontiers of our knowledge-based economy are advancing ever further, ever faster. New technologies, scientific advances - limitless possibilities. Never before have we understood as much about the world around us -

Nor appreciated how much more there is to learn. Everywhere we see opportunity and people who are eager to grasp it. We have schools, colleges and universities offering a wider variety of courses, qualifications and teaching methods than ever before. And we have clinics, hospitals and surgeries providing more drugs, operations and therapies than the founders of our National Health Service could ever have believed.

These are good things. The world around us is opening up. Diversity of knowledge, opportunity and ambition is empowering the majority in our society and driving us forward. But we must be equally aware that social mobility in our country has declined. For a sizeable minority of our people, progress has never seemed so remote: And their opinions never seem to have mattered less.

So I am glad that all that new knowledge and all that new empowerment have raised people's expectations of their public services. But we must also recognise that there is a massive challenge to empower the most disadvantaged. Access to education and health care should be fast, effective and tailored to individual need. But they should be tailored to the needs of everyone, regardless of background.

To do that we must recognise the failure of the centralising ethos that has marked out Britain's public services from those provided in every other developed country. Over-centralisation marginalises the weakest, the most needy. Bureaucratic complexity favours the strong and the articulate who are capable of making their own voice heard.

We must replace that philosophy - the one that says the man in Whitehall knows best - with an approach that recognises the challenge of providing modern services to Britain's highly diverse, varied society. We must hand power down from the centre to local communities and - where possible - to individual people too. Local services should reflect the needs, priorities and decisions of those who are directly reliant on them.

We must place people, not systems, at the heart of our public services. Today I want to talk to you about one specific area where I believe that we are failing those who are most in need. I want to talk about mental health services. And I want to explain what I believe government must do to improve both their quality and accessibility.

The challenge is daunting. One in four Britons suffer from a mental illness at some point in their lives: One in six is suffering at any given time. Whether it is you, your mother or father, son or daughter, grandmother or grandfather, aunt or uncle, niece of nephew - mental health issues directly affect most of Britain's families.

And we know that severe mental health illness in a parent has consequences for the whole family: It can even mean the removal of children into care when the related issues for the whole family are left unresolved. There is no doubt that the personal and economic effects of mental ill health in Britain are growing.

Look, for example, at the prescription rate for anti-depressant drugs among young people. In the mid nineties the number of prescriptions written for children in England was around 146,000 a year - In itself an alarming number. But in the last financial year the total had reached 631,000: The number of children being prescribed these drugs has quadrupled in just one decade. And prescriptions for children are just the tip of the iceberg.

Their parents too are swallowing more anti-depressants than ever before. In 2006 a total of more than thirty one million anti-depressant prescriptions were issued. What does it say about our society that we shrug at the explosion in anti-depressant use as if it were of no consequence?

But there are consequences - stark consequences. Britain has become the true Prozac Nation. I believe this trend has gone too far. We must cut the number of anti-depressants prescribed by doctors.

That's not to say that medication has no role to play in tackling mental health problems: of course it does. But they should not be the default option, prescribed by doctors because of a lack of access to psychological therapies. Anti-depressants come with risks associated with all medicine - dependency and the danger that they mask problems rather than cure them.

Pills must not be a crutch for the wider issues in our society which cause mental health problems. But if we want to achieve that we must ensure that alternative treatments are free and accessible. The rising human cost of mental illness has brought a rising economic cost too.

Since the current government took office in 1997, the number of people claiming incapacity or other out-of-work benefits due to mental ill health has risen every single year. Today, the total stands at more than 1,100,000 a year. But government figures for mental health expenditure don't include the cost of welfare.

In fact, when the costs of drugs and therapy are added to the costs of incapacity benefit, social care and missed job opportunities, the true economic cost of mental ill health is estimated at a staggering £77 billion every year.

That's the equivalent to cutting the basic rate of income tax by 19 pence in the pound. If the Chancellor were to do that, the standard rate would be just one penny. But why has this crisis in mental health been allowed to grow? Why is the NHS letting down these service users? And why have politicians shamefully chosen to turn a blind eye to the scale of mental health problems in Britain?

I say it is time to break the silence. We must bring the issues surrounding mental health from the shadows into the centre of our national debate on the kind of society we want to live in. When it comes to mental health the government's record is one of shameful neglect.

And their failings fall into three broad categories: Underinvestment, a lack of alternatives to drugs, and disempowered patients.

First, underinvestment.

It is true that this government has invested more money in the NHS as a whole. A lot more. And that increase in public spending was justified, though too much of it has been wasted on senseless reform and bureaucracy.

When the battle for PCT resources begins, mental health loses out Funding has been channelled into acute hospitals and away from mental health because of two Government initiatives. Acute hospitals and primary care trusts are under extreme pressure to deliver on the 18 week waiting time target by the end of this year.

And the money in acute care now follows the patient under 'payment by results'. But neither waiting time targets nor payment by results apply to community mental health services. The result: PCTs have less money left for block contracts to fund mental health services. At a mental health trust I visited staff told me that their funding has been cut over the last five years.

That is a hopeless situation. And with the money that is available for mental health, it has been channelled into acute services which benefit only 2% of mental health service users. The vast majority suffer from common yet disabling disorders such as depression and anxiety, and most of them never see a mental health specialist.

It's early intervention, community support, reduced admissions and ideas to help people back into employment that need attention. Because they are the key to reducing emergency emissions. But these are the very services that have been neglected.

This in turn exacerbates mental health problems: And this pushes up the number of detentions under the Mental Health Act. A cynic might say that the government's attention has gone into tackling the highest profile illnesses with the most vocal and empowered patients. Mental health services have commanded less favourable coverage, less government attention, and less money.

Second, a shortfall in alternatives to drugs.

The reality is that the Prozac Nation is founded on our lack of available alternatives to medication - medication which is often expensive. "Talking therapies" like Cognitive Behavioural Therapy aim to illuminate the underlying causes of mental illness and address them in a fundamental way. For some illnesses, like schizophrenia, we know that drugs are often essential. But for many psychological and psychiatric problems, therapies would tackle the root causes of the problem, rather than just help them to cope.

And early intervention can make a massive difference to prognosis. In theory, a GP should be able to refer people for these therapies. But in reality, waiting lists can be lengthy, therapists sparse, and specialists unavailable. NICE has recommended that a range of psychological therapies should be made available on the NHS. The government says it is trying to make that easier.

Indeed, last autumn the government announced an additional investment of £170 million specifically for psychological therapies. I welcome that. But the money was dedicated to building capacity rather than to ongoing running costs. And there is no guarantee that this investment will ensure access for those in need.

One study by Mind found that 93% of GPs are prescribing anti-depressants purely because they lack viable alternatives. Medical professionals want to prescribe effective, long-term solutions -

But in the absence of those solutions it is no wonder that so many drugs are prescribed. Central government has not only under funded services but it has failed to show the same enthusiasm driving up standards and cutting waiting times that it has demonstrated in other areas of the NHS.

Acute mental services will have to wait until later this year for an 18 week target to be applied, years after it has been applied elsewhere in the NHS. And no target or incentive has been applied to community treatments in mental health - where 98% of patients are seen.

This week my Shadow Health Secretary, Norman Lamb, has compiled a list of waiting times for both initial assessment and starting psychological treatments provided by mental health services across the country. The results that we have received tell the story of a lottery in mental health service waiting times.

Often the most vulnerable people are waiting scandalously long for access to treatment when all the evidence shows that early intervention is vital. In Leicestershire, the longest waiting time for cognitive behaviour therapy is almost a year and a half. In Gloucestershire you can wait almost two years for eating disorder treatment. And in Plymouth, patients can wait for over three and half years for a psychotherapy assessment.

This is a heartless, brutal way to treat some of the most vulnerable people in our society. Why is it that our television screens are full this week, rightly, with the suffering of battery fed chickens but silent on the scandalous way we treat the mentally ill in our midst? Mental health resources have been neglected and the services have suffered.

And my third point on government neglect just makes matter worse:

Mental health patients have been systematically disempowered. The old "custodial model" of patient care - with high levels of compulsory treatment - robs individuals of their autonomy. But it remains prevalent in Britain's mental health facilities. The most obvious manifestation of patients' powerlessness is the state of the wards that accommodate them.

Too often they are austere, dark, and deeply depressing. Many are of a condition that would never be tolerated in a district general hospital - and the assertive patient groups who use them. Some of the most vulnerable people in our care are being deprived of the basic dignity that stronger and more vocal patients take for granted in other parts of the health service. They are also less able to speak out against the ever present risk of abuse.

Between November 2003 and September 2005 there were 45,000 patient safety incidents reported on psychiatric wards - Including 122 sexual assaults, of which 19 were reports of rape.

A recent survey found that 58% of women in mental health hospitals were in mixed sex accommodation.

Just last week the Mental Health Act Commission described what they called a "truly scandalous and tragic situation" - whereby women are forced to stay in places where they fear for their safety. Those are the characteristics of mental health services in Britain today:

Well, that isn't good enough. And it needs to change. There is much that can be done to tackle mental illness by isolating its aggravating factors: factors that include poverty, unemployment, educational failure. And we have ideas for all of these areas and more.

But today I want to focus on the way the NHS itself can do so much more in its core role of treating mental illness. I am calling for nothing less than a revolution in how we treat mental illness. A fortnight ago, I spelled out my party's ideas for further improvement in the basic design of our NHS. We aim to create a health service that is both people-centred and personally empowering. And there is no greater need for that than within our mental health services.

At the heart of our plan is a Patient's Contract: A binding agreement between the NHS and every individual patient who uses it. That Patient's Contract would set out new minimum standards of care to be applied throughout every level of the health service. Out with the myriad of central targets and micro-management that have skewed doctors' priorities. And in with a new approach of individual entitlements which would apply as much to mental health services as to other core areas. These personal entitlements would cover access to information; rights to patient advocacy; availability of treatments and core services; options for redress -

And maximum waiting times. Where the NHS fails to meet those waiting times, the individual patient would be entitled to seek treatment from the private sector. And for mental health services, the waiting time must be short. Eighteen weeks is too long.

Early assessment and the provision of appropriate therapies are key to reducing drug-prescription rates and combating mental health problems before they have the chance to grow deeper and become entrenched. So by the year 2012 I want our health service to guarantee that no patient will wait longer than thirteen weeks for their first treatment.

We know that this can be achieved. In a recent clinical audit of specialist psychotherapy services at Southfield House, the agreed benchmark was a thirteen week maximum wait. And in some exceptional cases, pathfinder mental health services have reduced waiting times well below that level.

In Swindon and Wiltshire PCT, for example, there is a same-day service for mental health problems across the region. They have, in effect, abolished waiting times. Not all local health boards can match that level of performance. Swindon and Wiltshire is the exception rather than the rule. But a maximum wait of thirteen weeks from initial contact to first treatment is both possible and necessary.

And that's why I say that the NHS must deliver that service, or the patient will be entitled to go private. And it must apply to every service user, including those with specific needs. Young people are a particularly vulnerable group. NICE guidelines for example, say that children should not be put on drugs during the first three months of medical care for mental health issues.

So our thirteen week deadline is particularly necessary for Child and Adolescent Mental Health Services. Currently, one in six children referred to CAMHS must wait for six months or more before they are seen. And the result is that many are forced to seek help in less suitable environments. A people-centred health service ensures that every patient is cared for in an environment that is sympathetic to their needs and aids their recovery.

So the waiting times for CAMHS must come down. And under our thirteen week limit, they will. It's not hard of course to win sympathy for measures that benefit children.

Persuading people of the need to help prisoners is often harder. But the unpleasant reality is that seven out of every ten British inmates suffers from a mental health problem. If we choose to turn a blind eye to this we will leave some of the severest cases untreated - with devastating implications both for the prisoners and, potentially, for others in the community upon their release. So I want our mental health guarantee standard applied to mentally ill prisoners too.

And I want the money that the government has earmarked for more prison places to pay for new secure mental health treatment facilities. Because treating mental illness amongst prisoners is not merely an end in itself:

It is a means to reducing crime.

But waiting times are just one of the entitlements that we will enshrine in the Patient's Contract. High standards of cleanliness and care are another key aspect. The Royal College of Psychiatrists has an Accreditation for Acute Inpatient Mental Health Services (AIMS) programme that sets out exactly the kind of standards that are necessary. AIMS has established a high threshold for safe and dignified hospital treatment. Its Gold Standard should be an objective for all local services.

And let's be clear that the requirement to abolish mixed sex wards should go hand in hand with that Standard.

I know that has proven hard to achieve throughout the NHS. But mental health wards are a special case. Instead of lagging behind the rest of the NHS, this sector should be setting the pace. Mental health service users are often sensitive and vulnerable patients.

But they are also the patients at most risk from attack in mixed sex wards. The government has promised for over a decade that it will move to single sex wards. But its failure is hitting some of the most vulnerable women.

We have a medical service that has managed to cure cancers, conquer TB and replace vital organs. I do not believe that it is beyond the power of health care planners to separate wards between men and women.

Under our plans, every service user will be entitled to safe and secure accommodation that meets their needs, delivered by local health boards. And that includes single sex wards in mental health services. Now we all know that entitlements like these come at a cost. There will be short-term costs but there will be long-term benefits: both financial and personal. By spending more money on meaningful mental health treatment we can help people who would otherwise be on incapacity benefit get back into work. And we can cut the number of people who have become reliant on anti-depressants.

Similarly, at present NICE can only take account of the immediate cost to the NHS when it approves treatments for use. But that short-term thinking has long-term costs for us all. The total cost of an able-bodied adult on incapacity benefit is not the price written on the prescription form. It's the total sum pieced together from their benefit cheques, their own lost income, and the contribution they would have made to the economy had they been able to work.

NICE should be allowed to take those wider costs into consideration when deciding whether to licence new treatments including mental health therapies. There are also ways in which the NHS can work with other government departments to improve mental health care and generate long-term savings.

The Department of Work and Pensions, for example could pay money to the NHS when an individual is helped back to work through access to therapies. And employment support providers could also have the right to commission these services outside the NHS if the individual was experiencing long delays in accessing mental health treatment. That's the kind of smart approach that puts people's needs at the heart of long-term thinking.

A truly people-centred NHS must empower patients so that they have a real say in their own treatment. I want our health service to empower people, especially vulnerable people with more control over their treatment as never before. That's the way to rebuild confidence in themselves and their trust in other people.

Good Patient Advocacy is important too. The fear of stigma and discrimination discourages many people from seeking the mental health support that they need. Health professionals want to help patients, but in the minds of vulnerable people they can be associated with authority and regarded with suspicion.

All the evidence suggests that advocates can build trusting relationships with patients and give them the advice they need to make good, informed decisions for themselves. The government plans for statutory advocates for those with mental health problems to be introduced next year. But I want the patient advocates to be independent of the health service in order to build up as much trust as possible between them and their patients.

So we will pilot a network of independent Patient Advocates dedicated to providing information, guidance and support to both mental health patients and carers. And under our plans there will be real choices for patients to take. Social services have used direct payments and individual budgets to empower people to decide how their care is administered.

The same principle should apply to mental health service users. I want to see care budgets granted to those patients who are able to make informed choices. These will present a menu of care options from which they can select. Under our plans, and with advice and guidance from clinicians, many patients will literally be able to decide on the therapies and therapists that they want.

After all, the modern world is all about opportunity and empowerment:People thrive on independence and self-help. So we should be willing to experiment with new ideas to bring those values into health care.

In the case of mental health, for example, the NHS Chelmsford and Essex Centre cooperated with a groundbreaking University of London study into computerised cognitive behavioural therapy. By allowing people to tap into an electronic support programme with minimal supervision, the study estimates that cognitive therapy capacity could be increased by around 25%. The pilot was aimed at those with mild to moderate depression.

And it clearly depends on a degree of confidence and computer literacy. But where innovative treatments have a role to play - And where they can hand control and self-reliance to those who need them - The health service should be quick to embrace new and empowering ideas.

But improved personalised, patient-centred care and experimentation with ideas cannot be delivered from the top-down. Service providers must shape health care around the specific needs of local people. That's why we would devolve power and responsibility down from the Health Secretary's desk to local NHS commissioners and to the communities that rely on them.

It is time to make Primary Care Trusts democratically accountable to the communities they serve. We would turn them into Locally Elected Health Boards. This is not yet another reorganisation: there will be no transfer of employment. Rather, this is a fundamental shift in accountability - With local people empowered to imprint their priorities on their health services. That's why decisions should be taken as close as possible to those who are affected by them. This is not just about pushing up the standard of service.

It is about translating national health services into local health settings. And giving a human face to the centralised monolith of the NHS. So my vision for the future of mental health services is part of my broader vision for the future of our health care system.

I want our NHS to place people at the heart of its service. I want our NHS to guarantee quality care, tailored to the needs of individual citizens. And I want our NHS to empower patients with control over their own care, just as they have gained control over so many other aspects of their lives.

Mental health service users are perhaps the people who most need an approachable, effective and enabling NHS. We will know that we have succeeded when it opens doors to a brighter future for them.