Oral evidence: Improving Access to Mental Health Services, HC 80

Oral evidence, 15 June 2016.

Witnesses

Andy Bell, Joe Rafferty, and Dr Gary Wannan.

Chair

Good afternoon and welcome to the Public Accounts Committee. We are here today to get evidence and look at mental health services on the back of a National Audit Office Report, “Mental health services: preparations for improving access”. This is an area to which both this Committee and the National Audit Office will return a number of time during this Parliament, because it is obviously a hugely important issue and one on which there is a major Government policy shift, although it hasn’t quite happened yet, which is one of the things we are here to discuss today. We are delighted to have a pre-panel today of experts in the field actually at the sharp end trying to make sure that Government policy gets delivered. We have on my left Andy Bell, deputy chief executive at the Centre for Mental Health; in the centre is Dr Gary Wannan, who is senior consultant psychiatrist at Central and North West London Central NHS Foundation Trust; and then Joe Rafferty, who is chief executive of Mersey Care NHS Foundation Trust. Welcome to you all. We hope you will be candid in your comments—we take what you say very seriously—and after you we have the Department and NHS England to put your points to, as well as what is in the Report. Why does parity of esteem between mental and physical health seem to be so difficult to achieve in practice? That is quite an open question. Perhaps I will start with you, Mr Bell, and then work across.

Andy Bell

The first thing to say is that we are starting from a low base. Mental health support at the moment receives around 12% of NHS funding—I think that is what the NAO Report said—and accounts for about 23% of need. That is quite a big discrepancy. We know from freedom of information requests that that varies from one area to another, so different CCGs are starting from different places in terms of their support for mental health. We also know that there is a range of other disincentives to create a fair situation for mental health. That includes the different funding systems—the fact you have a tariff for most acute hospital-based care and mental health care is paid for, with some tweaks, in what is still a block contract, so the provider gets paid a certain amount a year rather than being paid for the number of procedures it carries out. Also, we still have a system where accountability is skewed towards other areas, so it is only this year that for the first time, we have had access and waiting standards. The NAO has focused on those, but they are only two of myriad areas of mental health support, and the rest is very opaque in terms of what is going on, what standards of care are provided and how quickly it is done. Then there are a couple of things. One of them is that mental health is very often overshadowed, so we hear endlessly that there are limited resources in the system, and when it comes to decisions being made locally, there is always something that feels a bit more pressing and where there is a more shrill case, if you like, for support. There is always a higher burden of proof to do something different. It is easier to stay the same, and to carry on as we were, just making little tweaks to it. There are a number of disincentives that stop us making as much progress as we might.

Dr Wannan

I concur with Andy’s very full answer. Starting from a low base as we do, there is a lot of progress that needs to be made. One thing that has struck me over the years is that the very good intentions that Government often has simply do not translate to what happens on the front line. I can remember even 13 years ago, when I began my consulting post, being somewhat excited by the new funding that would be coming to child and adolescent mental health, seeing the framework behind that and then, with the smoke and mirrors that went on, actually being left with much less resource than had been anticipated. As Andy said, there may often be more pressing needs or other things going on within the wider system that simply militate against the good intentions of central Government.

Joe Rafferty

Again, I concur with what has been said. I might add that there has generally been a low expectation of mental health services, first of all by those using the services. They are often very disfranchised people; many have had to struggle very hard to get into services. That, I think, combines with the public view—there is probably not enough education about the reality of mental illness and mental disorders. We still encounter lots of people who have a “Pull yourself together” attitude, or “This is a lifestyle choice”—we see that particularly around addiction services. We would argue very strongly that there is a strong line of mental illness in people with severe addictions, yet it is sort of seen as a lifestyle choice.

Stephen Phillips

Is that public view changing, or is mental health still the Cinderella of the NHS?

Joe Rafferty

I would say it is still a Cinderella, but I think because of better public appreciation in the past couple years, much more political focus on the question of mental health and the economic benefit of addressing it, NHS England’s comprehensive review and the taskforce report, as well as the intention to invest more, put us in a position that is better than we have been in for probably the past 15 years or so. The question is how to capitalise on the opportunity now.

Chris Evans

Mr Rafferty, you made an interesting point about addiction. I have been very interested in addiction and the link between addiction and mental health. In the last Parliament I was a member of the Justice Committee, and I felt that when a prisoner was incarcerated, they treated the addiction but not the underlying mental health problem. I felt that was a huge issue out there. Do you think that a lot of money directed towards addiction treats the symptom rather than the underlying cause? How can we overcome that and get value for money?

Joe Rafferty

My view is that that is an absolutely correct observation. We are trying to tackle that internally as an organisation, and I know lots of others are. For me, the issue is that our experience of addiction services is that they are incredibly underfunded. They tend to be put out to tender on a regular basis, and there are lots of small organisations focusing on addressing the addiction. The result of that is that it is really hard to find anywhere an addiction service with the sort of critical mass required to put psychology and psychiatry in and make it much broader and fuller in both assessment of and response to the underlying nature of the issue.

Chair

For anyone who is following us or wants to comment on Twitter, I should say that our hashtag today is #mentalhealth. You have all highlighted that we are starting from a low base. The Government has set out a grand vision, but at the early stages a simple set of targets on waiting times—the sort of things that people with a physical problem have come to expect for some time. Andy Bell, you have talked a bit about this. What are the particular barriers to that? Is it the funding or is it the culture of how these services are organised? Perhaps we will start from the other side with Joe Rafferty and go back the other way. We will take Gary first another time.

Joe Rafferty

I think that both your suggestions are right. It’s a little bit about how services are organised. Unquestionably, at least for a period of time, it is about some element of funding to pump-prime change. One of the difficulties in addressing this issue—I welcome the waiting time standards—is that it is a bit like a magnet with iron filings: if you hold it up, all of the attention goes to wherever you have put a specific target. I wonder whether we will end up improving bits of the system quite well, but if your presentation doesn’t relate to early intervention in psychosis, IAPT or whatever, you will remain out in the cold. What I would like to see is a comprehensive waiting times backstop for all secondary mental health services.

Chair

So you think that is feasible. One could argue that the Government is putting it this way to take it step by step, but you think it is possible to do it all at once.

Joe Rafferty

I understand the step-by-step issue. I get that, but what would have happened if we had started in acute care with a two-week cancer wait and a four-hour wait in A&E, but hadn’t addressed anything else? I think we would have pushed those things really rapidly, but the rest of the system would have felt like it wasn’t getting attention. Why is mental health somehow out in the cold? We didn’t do that for physical health. If the issue is parity, why, if you don’t fall inside those current waiting times guarantees, do you have no guarantee at all? I think it is perfectly feasible. It makes us all sit up and decide that everybody with a mental illness who needs access to those services is important. It will make us fundamentally change how we think about delivery. Just having to think about it will make us more efficient.

Chair

Mr Rafferty, it sounds like you are recommending yourself for a national advisory position. The permanent secretary is sitting looking rapt behind you. Do Gary Wannan and Andy Bell have anything to comment on what Joe Rafferty has just been talking about?

Dr Wannan

Child mental health has been described by some as the Cinderella of Cinderella services. Between 2010 and 2015, it is estimated that about £85 million in total was taken out of child mental health, despite the intention of increasing funding. If one looks at the amount invested by the NHS and local authorities, one can see that there has actually been disinvestment. We all know that mental illness follows a life course, and that by investing at an early stage we are going to save money in the long run. In terms of new resources, one of the things that encouraged me considerably was seeing the Government and clinicians like me and others working together over the children and young people’s improving access to psychological therapies programme. We saw very clear training and goals, and we have seen progress, but more needs to be done to think strategically about how we can best use new resources to find ways to invest to save, among other things, and to make sure that there are not smoke and mirrors and that the Government’s commitment does not wither.

John Pugh

We have had a submission from the Association of School and College Leaders. They polled their members, who were asked what they thought works well in terms of children’s mental services—that is what you are drawing attention to—and 43% said they were very happy using in-house counsellors and least happy with the referral process to CAMHS and other psychiatric treatments. One in five reported that they were very happy, but nearly two thirds reported that the experience had been poor or very poor. Is that entirely a consequence of funding, or is a consequence of the wrong service being provided in the wrong way?

Dr Wannan

I am not sure I can give a complete answer but—thinking about school counselling—schools are a great place to reach children and young people. That is where the great majority of children and young people are sure to be found. Having a school counsellor or a children’s mental health worker embedded in schools is a great way to reach out. If there are any choices to be made about funding, that would be one of the first places that I would be emphasising. I sympathise with the comments made about accessing child and adolescent mental health services. The Children’s Commissioner’s enlightening review of CAMHS services that was published recently shows a huge national variation. In some CAMHS, the waiting time might be seven months. In others, it might be two weeks. It comes back to my comments that there needs to be strategic investment. We as clinicians need to be motivated and sometimes roughed up a little bit by the Government to ensure that we are making the very best use of our resources and to ensure that we—

John Pugh

The Government might take up that invitation.

Chair

The Government are excited behind you. I wish the cameras had another angle. Sometimes we get a bird’s-eye view.

Andy Bell

We would be happy to do that from the voluntary sector as well.

Chair

Rough them up?

Andy Bell

In terms of the access and waiting standards we have at the moment, the biggest barrier appears to be workforce availability. You need to have trained people to carry out the interventions according to the evidence. In lots of areas of mental health support, unsurprisingly, if you have unqualified staff or staff who are not properly supervised, sometimes the interventions can do more harm than good. It is very important that you have the right people with the right skill to give people the support they deserve. There is something about building up a workforce that is capable of meeting the standards in all the areas. To pick up on the issue of schools, we have recently finished a major review of children and young people’s mental health. The stark finding that came out of that was that it typically takes 10 years between the first symptoms of a mental health condition appearing and a young person having access to effective, evidence-based support. That is a range of delays based on low mental health literacy, on parents finding it hard to know the difference between a mental health difficulty and just ordinary stuff happening in childhood, and on what parents and young people described as a maze-like way of getting into services. If a parent asks for help, schools very often do not know what to do. Unfortunately, when people end up in services and make contact, they often find a remote, formal, frightening, clinical feeling, so even when people get access they very often walk away and do not maintain contact. We have to look thoroughly at children’s mental health. I hope very much that the access and waiting standards that we have are just the first few of a number that address this by actually using the evidence of what an appropriate amount of time to wait is. We should ensure that people are getting access to support in a way that is timely and takes advantage of them asking for help.

Karin Smyth

I want to pick up on the system, which you have all talked a little bit about. If we were looking at mental health as a whole, we would have about 20 different people in front of us, particularly people from housing and other providers. Would you all say a little bit about the financial incentives in the system? How might they be better to get you all working a bit better together?

Dr Wannan

As a clinician, my incentive comes from the needs of children and young people. I know that it is nearly always the best thing for families for me to help to bring professionals together to ensure that the package of care and treatment received is well designed and well planned, so that we do not overuse resources or swamp a family with professionals, but that we target children.

Karin Smyth

Are you purely hospital-based?

Dr Wannan

I am based in a clinic in the community. I will do a small amount of work in hospital, but a lot of time I may be out in families’ homes or going to the housing department or social services, so for me, it is instinctive almost to bring professionals together, to work together efficiently and in the best way for children and families. I am not sure the financial incentive would necessarily change the work I do in that respect.

Andy Bell

In almost every area of mental health we look at, partnership working and coming together are really important. Sometimes, we see integration in two-dimensional ways when it actually works in three. Sometimes it is about primary care working with specialist services; sometimes it is health and social care working together; sometimes it is mental health and physical health; it is also relationships with the police, housing and employment services. In almost every case, the incentives—the hard wiring of the system, as the taskforce usefully called it, seems to militate against that happening. It is much easier to commission and provide services on your own, rather than in partnership. When times are tight financially, we see drawbridges going up rather than people making arrangements to work together. We have long-standing arrangements in adult mental health where social care tends to be part of a community mental health team. I certainly heard anecdotal reports of those arrangements coming to an end, which is clearly a very backward move when we know how important it is that people get joined-up support. Likewise, joining up with housing is incredibly, fundamentally important. With something like employment, there is a real disjunction at the moment between the kind of support people are getting in the NHS—some of which is very good, and where there are evidence-based employment services—and the experience they are having of the DWP’s programmes, which, for people with mental health problems, is extremely difficult.

Joe Rafferty

That is a really great question. As Andy says, in difficult times, partnership can be really hard to do because it is often down to will rather than financial incentives. Sometimes, the financial incentives could be made easier, though. I will give you a simple example around the A&E liaison services that we provide, which we have to do in partnership with the acute trust, police, social care and so on. For us, a great incentive would be a very simple thing like having our staff funded on recurrent money[1], so that we can give them real, long-term contracts, attract the best people in and make the liaison service feel like it’s a real career move.

Chair

When you say “your people”, are we talking about particular clinical groups?

Joe Rafferty

Our liaison nurses, some of our social workers—we are offering six-month and twelve-month contracts.

Karin Smyth

Is that because those liaison services are pilots or perhaps perceived as short-term interventions at that particular time, so they are not part of the general make-up?

Joe Rafferty

That’s right. There is always this view of, “We’ve got to see how this works.” The truth is that getting over the hump and trying to get people in so that they can invest real time and energy—the partnerships work then, because you build long-term relationships. Sometimes the incentives could be as simple as that.

Stephen Phillips

I want to go back to Mr Bell, and probably to you, Dr Wannan and Mr Rafferty, on the question of staffing, at the risk of telegraphing some of my question to Mr Wormald in due course. Let us look at the Report prepared by the NAO, of which you have a copy. In figure 13 on page 46, there is quite a discrepancy between the numbers of staff working in mental health that the trusts think they want between now and 2020, and the demand as predicted, for example, by the King’s Fund. I wonder what your views are on that, first as to who is right, and secondly as to how those discrepancies are going to reflect themselves in improved access to mental health care over the course of this Parliament. Do you want to start, Mr Bell?

Andy Bell

If I could find the correct page—

Stephen Phillips

Page 46, figure 13. If you look at the figure first, you can see the divergence—the fork in the graph. If you go to the preceding page and look at paragraph 3.27, just look at the second sentence: “There is a considerable discrepancy between numbers that local providers estimate are required, and Health Education England’s forecasts. Trusts forecast, for example, that their demand for mental health nurses will fall over the coming years. Health Education England, however, estimated that implementing access and waiting time standards would require the number of mental health nurses to rise from 39,000 in 2014 to 42,000 by 2020”. So we have one picture from the trusts and another from Health Education England. Not having the staff, if they are needed, is obviously going to reflect itself, I would have thought, in poorer mental health services, poorer access to mental health services and defeating the objectives the Government appear to have. That is the area on which I wanted the views of all three of you.

Andy Bell

In this area, it is certainly fair to say that, in the time I have been working in the sector, workforce planning has not been a strength in terms of the way in which services and national strategies have been developed. It has not been a major factor in any of the recent strategies—probably not since the national service framework in 1999, which had a very clear sense of the workforce that would be required and how it was going to be brought together. This needs to be thought through, because obviously we need enough people on the ground to do the work and we also need to look very carefully at what workforce we need, particularly if we are focusing on earlier intervention. We need to think about what people with what skills we need—it is not just, “Do we need X number of nurses and X number of psychiatrists or psychologists or anything else?” There is certainly a growing role for peer support workers, who can very often be a very valuable part of any clinical team, or employment specialists, who can provide support with work. This probably calls for a proper look at what workforce we need, taking a long-term view that looks considerably beyond the five-year horizon we have now. It is about identifying what skills and what people we need, and how we can get them. I suspect that will take quite a bit of work.

Dr Wannan

Staff are the core of the service we provide.

Stephen Phillips

You can’t do it without them.

Dr Wannan

Exactly. The great majority of our work is done through talking treatment, so workforce planning is vital. It is helpful of the National Audit Office to have made this point as clearly as they have. When we look at young people and what they say about the services, what they most value is quality and continuity in the relationships they have.

Joe Rafferty

One of the reasons I welcome the current review by NHS England of mental health—by the taskforce—is that it starts to give us a longer-term view. The interesting thing is that there is, I guess, about a three-year lag in all this, so you have to be making decisions now about way into the future. That is why this is such a critical point. I do not know entirely about Health Education England—I can only talk about my own organisation in that sense. We have quite a clear five-year view of where we want to be, how our staffing numbers reduce through attrition and retirement, the types of services we intend to deliver in the future and what type of workforce we might need and want. For example, nurse associates is another alternative to training nurses in a traditional way. There are physician associates. We are now recruiting our 17th or 18th peer support worker in the organisation—people with lived experience who deliver a really different view. I guess the issue is, because of the lag in this, that we absolutely have to get it right. I argue, from my perspective, that we have a clear view. Whether that aggregates to the right view at the Health Education England level, I couldn’t comment.

Stephen Phillips

It is being suggested to me in real time by a very senior mental health nurse that trusts frequently underestimate staffing needs at the outset. Jobs are calculated on tasks, rather than the actual time you need to spend with patients.

Joe Rafferty

Correct.

Stephen Phillips

Is that a fair criticism of what takes place across trusts at the moment?

Joe Rafferty

My view is that traditionally, we have looked at the staff we have and we try to work out what service we can deliver with the staff we have, which I think is the wrong way to do this.

Stephen Phillips

Yes, isn’t that completely the wrong way around?

Joe Rafferty

Correct. The way to do it is to have a clear view of the care model—what you are trying to achieve—and then work backwards to look at the opportunities to think differently about the types of staff. To use the model that you suggest, we should ask, “How much time does someone need to do this?”, rather than simply, “What’s the task?”, because the task tells you nothing. The task tells you nothing about the acuity of the patients in front of you, the treatment pathways, the handovers—all those things. I think we need to get a lot slicker at workforce planning generally.

Stephen Phillips

I do not want to prolong this unnecessarily, but Dr Wannan, do you want to comment on that?

Dr Wannan

Yes. I think that with the new money coming into child mental health that the Government have promised, workforce planning is vital. That money needs to be spent well. I was speaking earlier about investing to save. There are huge opportunities to save money, such as being able to give intensive community provision for young people, rather than admit them to an in-patient bed. We need to make sure that we have the right workforce in place and to look creatively and strategically at how best to use resources.

Stephen Phillips

Very briefly, Mr Bell.

Andy Bell

I do not want to comment on how trusts do their workforce planning, because I don’t know, so it would be unfair. The other thing to say is that the mental health workforce is a lot bigger than the people employed by mental health trusts. When you think that 90% of people who receive any treatment for a mental health difficulty only ever see someone in primary care, so GPs and their staff are an incredibly important part of the workforce. People working with children in schools and in youth services are all part of the workforce. I think we need to see that broader set of people outside the system. I have seen from data from the NHS Benchmarking Network that staffing, particularly nurse staffing in in-patient services, has increased over the last few years, because of safe staffing, following Mid Staffs. I think that creates a very particular pressure on wards to make sure that they have enough people. The average in-patient ward has a bed occupancy rate of 93%. The safe occupancy rate is 85%, and that is excluding people on leave, so there is enormous pressure in some of these services. I think there is a culture of making do with the resources available, which you don’t get in other parts of the NHS so much.

Chair

I just want to advise Members on who is coming in when: John Pugh, David Mowat and then Chris Evans. I am aiming to finish this segment of our hearing by about twenty past, so could the witnesses bear that in mind? If you agree with someone, we are happy for you to say you agree—you don’t have to repeat, though we welcome your evidence.

John Pugh

I just have one big question and one quite small question, to Mr Rafferty, while he is there. One of you mentioned the system a few minutes ago and we have some submissions that show that people are occasionally baffled by the system and the lines of accountability. I would like you, just briefly, to comment on that, because if we look at how a patient with an often extremely troubled psychology is treated, and with a very fretful family, they normally find the entrance point to the system via the GP, who refers them to some provider, who is commissioned by a third body. The provider—I think I am right in saying this, Mr Rafferty—can sometimes just diagnose and then refer on to another provider, who provides the treatment. That is fine when everything goes seamlessly, but when things go wrong and the treatment isn’t working—there are certainly some touching accounts in the submissions we have had about when it hasn’t—it doesn’t seem an ideal set-up. I was mindful when preparing for this that there are some areas where commissioning is done slightly differently or better or more wisely. I would just like all of you to comment on the accountability factor. Who is responsible ultimately for the troubled patient?

Chair

Who shall we start with? Well, you asked Joe Rafferty.

Joe Rafferty

I think that we have probably talked about this before in other times. You are absolutely right. It can be an incredibly difficult set of pathways to negotiate. For example, as a secondary provider, we have about 19 different ways into the trust—19 different routes of referral in—and therefore a multitude of different connections to make. It would be much easier, I think, if we had a system where we could rely more heavily on a referring practitioner—a general practitioner as the core, until somebody absolutely moves into another part of the service. I guess the difficulty is that many of these services have grown up over years, been commissioned in very inconsistent sorts of ways, and there are lots of legacy systems in there. That doesn’t excuse it, but it is probably a description of why the history of things is as it is. I think we are seeing now quite a big move, certainly with the CCGs that we work with, to bring the various agencies round the table and have much more of a multidisciplinary-team-type approach. I am absolutely certain that that is going to resolve quite a lot of the issues, with a very strong sense of making sure that we navigate people—not just diagnose or treat, but assist with navigating to the next right place.

Dr Wannan

I agree it’s confusing for patients, and it is my job to explain the system to them and make it very clear—

David Mowat

You’re able to?

Dr Wannan

Yes. I think that if I meet a family and I am clinically responsible for the child, it is my responsibility to let them know that that is the case and confirm that in writing, as it would be for anybody else who works in my team. There may be times when we have overlapping responsibilities, but as well as asking the question about who is responsible clinically—coming back to the issue of resourcing and so on—I sometimes ask myself the question: who is responsible for the resource allocation? My experience is that these clinical lines of accountability are sometimes clearer when we have some of the financial, managerial—

John Pugh

But neither is particularly clear, to the patient at any rate.

Dr Wannan

Yes.

Andy Bell

Again, it’s the way parents and young people particularly describe the difficulty in navigating services—having to do it themselves. The NHS is a gatekept service, so general practitioners are really important in terms of being the advocate for somebody to make sure they get access to a service. If we put as much effort into providing support as we do into assessing people and excluding, we could probably have a much more productive set of services. But accountability is troublesome throughout the system, throughout the NHS. In what way is there accountability for how much we fund mental health services in each local area? At the moment, it is very unclear where that line of accountability is and who is responsible.

David Mowat

We started the session with the question of why parity of esteem is or seems to be so hard to achieve. What strikes me is whether or not the Government or the system has been honest in its intentions in all of this, we have put this objective out there, into a system that is under such pressure in so many other areas. We have a situation where 80% of acute trusts have a deficit. We have a massive shortage of GPs. So whereas the objective is clearly a good one, it does not necessarily say what we are not going to do as a result of having that objective, and because of that, it is not totally honest. And it just struck me, reading the Report, that one of the issues that arises is that when money is given to clinical commissioning groups and is not ring-fenced, it tends not to get spent on mental health stuff but on other stuff, presumably because those people have decided they have other and—in their opinion—more pressing needs. I just wonder whether we are trying to do something here that is honest.

Chair

No one wants to go first on that one. Andy Bell.

Andy Bell

Parity as an idea has really resonated in lots of places and been used very creatively by people in local CCGs and councils to make a difference, so it has had a resonance in local areas, which has been incredibly helpful. I think it’s entirely achievable. It certainly would be a shame if we got further from parity and I think we can get closer to it. The way we can get closer to it is to recognise the waste at the moment in spending, in the NHS and other public services, on failing to support people’s mental health. The NHS spends as much again if not more on the consequences of untreated mental health problems among people with long-term conditions like diabetes and people with medically unexplained symptoms who are having endless out-patient tests. A whole range of people are getting very poor care at very high cost.

David Mowat

That answer implies that parity of esteem over the life cycle, if I can put it like that, pays for itself.

Andy Bell

There is no question about that. An analysis we have carried out shows that if you refocus and reinvest in effective early mental health help and integrating care across that great divide with physical health, it will pay a dividend.

Dr Wannan

I very much agree with what Mr Mowat said and I come back to the idea of investing to save. We should be looking to spend money to free up other resources. It is cheaper but also much better for young people to receive intensive treatment in the community rather than being admitted, but it requires strategic and long-term committed planning to be able to do that. I am concerned as well that with targets—for example, we have a target by 2020 to see all children and young people within four weeks of referral. I very much agree with that goal. That is a good thing. A six-month wait is a long time in a child’s life. My concern is that we will simply remove something else, so the time for treatment may simply be increased to shorten the time for assessment.

David Mowat

In his very first answer, though, I think Mr Bell made the point that 12% of resources go into this area and 23% of need—however that is measured—is in this area. That implies that you think that there should be more resources put into this area, although the two of you who have answered so far have said that actually, over the life cycle, it is not a question of more resources, because you save more by doing it earlier. I have heard that before. Which of those two positions do you take?

Andy Bell

From my point of view and from the research we have developed, I think we should spend more as a proportion on mental health. I do not know what the right proportion would be—I think it would be different in different areas—but at the moment there is an underspend on mental health. It is about identifying where there are opportunities to make change. It is incredibly difficult at the moment.

David Mowat

I agree. That looks to me to be the case, but if we think we should be spending more on mental health, as your first answer implies—

Andy Bell

Absolutely.

David Mowat

A strategy that says parity of esteem, which is clearly a good one, works extremely well until we find out what we are not going to do as a consequence of that, perhaps in some other area, such as—I don’t know—cancer drugs, fewer GPs or something. That is where the difficulty arises, presumably, for those people who are making those resource decisions in the clinical commissioning groups and in other places. That is the issue that we may not be addressing properly.

Chair

Quick-fire answers, please.

Andy Bell

There is a risk in making that change, but there is also a risk in staying where we are, which is that we continue to treat people badly and pay the costs. As a perfect example of where you can shift resources, we know that if you invest in liaison psychiatry services in general hospitals, you can reduce the number of admissions and the length of stay of very vulnerable patients. In some hospitals where they have invested in liaison psychiatry, they have actually been able to close wards—in-patient wards, which are very high cost.

David Mowat

Right. But that answer is internal to the mental health area; it is not saying that there is an area that is going to lose out.

Andy Bell

No, that is within physical health. That is in an ordinary hospital—a district general hospital—shifting a bit of resource across to mental health, which is a relatively small service in the context of a huge NHS. As an example, to provide psychological support to people with cancer, who have very high rates of poor mental health, would cost 0.2% of the cancer budget. It is a tiny bit of the resource that would be needed to provide people with a little bit of extra help, which might help to improve their quality of life markedly.

Chris Evans

I am deeply concerned. Obviously, there is an understanding across the panel that secondary school-based counselling is extremely important in terms of child mental health. There are 70,000 to 90,000 cases in secondary schools each year. What worries me is that according to the British Association for Counselling and Psychotherapy, provision is very inconsistent and patchy across England. However, Wales and Northern Ireland have national school-based counselling programmes. What is the problem in England? Why have Wales and Northern Ireland in particular recognised this problem while England is so far behind the curve?

Chair

I don’t know which of you is qualified to answer this one. Who can answer it? Andy Bell is offering himself again.

Andy Bell

I can have a go at a bit of the question. I know the reason Wales invested in school-based counselling. Unfortunately, it was as a result of the spate of suicides in Bridgend. That was the motivating force; they felt that they had to make a response. You have to build the evidence base first of all about—

Chris Evans

Sorry to interrupt. That was a direct response to what was happening in Bridgend in 2008-09—yes?

Andy Bell

That is my understanding, yes. It was a response by the Welsh Assembly Government to concerns about that. Why are we not doing it in England? That is a good question. We know that schools have a really important role. School counselling is part of what we describe as a whole-school approach. You might have only one thing in a school. If you have only counselling and you do not have anti-bullying support, you do not have it on the curriculum and you do not quickly identify children who are having difficulties—actually, the way you get the right results is by having a school that embeds mental health across all the ways in which it works. It should train up teachers in mental health awareness. If you are a primary school—primary schools have as big a role, if not a bigger, in supporting children’s mental health as secondary schools—it is about working with parents and families and identifying families who are struggling to manage their children’s behaviour. Children with behavioural problems go on to have the poorest life chances and the most diminished future opportunities in life. It is about embedding a whole-school approach. That is what we have to get closer to and where there is a big prize, and it will be incredibly good value for money.

Chair

We have the permanent secretary before us in a moment.

Mr Bacon

Dr Wannan, you have repeatedly mentioned invest in order to save. How much investment would produce how much saving?

Dr Wannan

As much as you want to give me; that is the easy answer.

Mr Bacon

Well, it is an easy answer to the first part. You have invited the Government to rough you up. If I were Mr Wormald, I would want an answer to the second part. In fact, I also want an answer to the second part. How much money would you save?

Stephen Phillips

For every pound invested.

Dr Wannan

I do not have the answer to that readily available but, with £1.25 billion promised over the next five years, I hope that will make a substantial difference to the services that can be provided.

Mr Bacon

It is the saving that I am after—the number. Would £1.25 billion save £600 million or £3 billion?

Dr Wannan

I can’t give you the answer to that. Look, for example, at the research that has been done on intervening in parenting when children have a conduct disorder—behavioural problems. I do not have the figures in my head but there is clear evidence to show that the return on every pound is quite colossal in terms of the amount of money saved through these children and young people being diverted away from the criminal justice system and the like.

Stephen Phillips

If there is some research on that, would you mind sending it to us? Just signpost us to the research.

Dr Wannan

I am very happy to do that.

Mr Bacon

I am not saying that you are wrong. You may very well be right. I was interested in Mr Bell’s example. I am just saying that if you are going to persuade people, you will need evidence.

Dr Wannan

I am very pleased to furnish that.

Chair

There is a figure in the NAO Report that I am just going to ask them to highlight.

David Raraty

There is the widely quoted number that mental health problems cost the whole UK economy an estimated £105 billion a year.

Mr Bacon

£105 billion?

David Raraty

£105 billion.

Mr Bacon

So, that is one seventeenth of GDP.

David Raraty

Which is substantially more, of course, than we spend on treating mental health conditions.

Mr Bacon

That is almost the entire NHS budget—not quite, but nearly.

David Raraty

How much of that you would save depends on the effectiveness of the mental health interventions, perhaps.

Joe Rafferty

There is a good economic analysis of the benefits of intervening with mental health at the back of the Mental Health Taskforce document. I cannot remember the aggregate invest to save figure, but it is often two and threefold. For every pound spent, you would liberate or release £2 or £3.

Mr Bacon

If you could send us a memo with some details, we would welcome that.

Chair

A couple of quick questions from me before we finish. The first is about the well-known fact that, nationally, black men have a higher estimated rate of psychosis than white men. I know that is an issue in my constituency. More are also admitted into hospital. There seems to me, as a constituency Member of Parliament, to be a real issue about equality in mental health treatment. Would those of you who feel qualified each give a comment about why you think that is and what could be done to make it better?

Andy Bell

There are numerous inequalities. The experience of African and Caribbean men and women in the mental health system is—

Chair

Women in general or Afro-Caribbean women?

Andy Bell

African and Caribbean women. There is a very serious discrepancy in what people are diagnosed with, and what care and support they receive. There have been numerous efforts to try to address that—some with funding—and it does not appear to have made a huge amount of difference. We are quite keen to see what interventions can be offered to people younger in the age spectrum to prevent people from coming into contact with the mental health system through the police, which is often the route that leads people into that very negative cycle. Lambeth Council has done some terrific work with the African and Caribbean community in the borough to identify what support they would like in terms of earlier intervention and the support people get. There are other inequalities that are hidden and serious. People from lesbian, gay, bisexual and transgender backgrounds have much poorer experiences and much higher rates of poor mental health. In terms of people with learning disabilities, there is very little in the way of evidence around what help and support people want, but we know that there are very high rates of poor mental health. There are lots of inequalities, and if we want parity between mental and physical health, we also have to work towards parity within it.

Chair

Absolutely.

Dr Wannan

Building on that, with the Government’s emphasis on parity of esteem, part of that is destigmatising mental illness. Different cultures have different ways of thinking about mental illness. Any progress that can be made in that area is very welcome. With the increased emphasis on early intervention in psychosis, I can talk about my own experience of being in an early intervention psychosis team, where efforts were made within the community to increase public education.

Joe Rafferty

The only thing I would add is that cultural sensitivity of how services are offered, not just how early, is probably a major route into this. We have some evidence from working with the Somali community in Liverpool that cultural sensitivity is a really big issue.

Chair

Do you have anything you can send us on that?

Joe Rafferty

I can do.

Chair

A quick-fire final round. We have the permanent secretary and the head of NHS England in front of us next. What two or three things do you think would move this agenda forward appropriately and quickly? Obviously, we are in the early stages.

Joe Rafferty

Commissioning, funding and information to make better decisions.

Chair

Very succinct, thank you.

Dr Wannan

Auditing the promises made by Government—

Chair

The auditors are smiling. You are currying favour.

Dr Wannan

—in terms of what is exactly spent on child and adolescent mental health.

Chair

So actually knowing the data, which, as the Report highlights, is an issue.

Andy Bell

I can’t be that quick. Accountability, transparency about funding in mental health in every local area—we need to have real-time data on what is being spent on what, and there needs to be some kind of accountability for doing that. Sustainability of transformation plans have not been talked about. They are the big thing in the NHS at the moment, and we need to ensure that mental health has a fair crack of the whip in those. It would be absolutely disastrous and a backwards step if we had 44 of these plans come out and all of them increased the disparity. We have to make sure that they are treating mental health fairly and appropriately and working towards parity. We need infrastructure, to help people locally to implement that big taskforce report and do the things they need to do. They are not going to do that without support. We need to have a proper infrastructure to make that happen.

John Pugh

Are you saying that there is a lack of predictability in infrastructure plans?

Andy Bell

I suppose I mean infrastructure in terms of support through—

John Pugh

Human infrastructure. There is a capital programme as well.

Andy Bell

No, that’s not what I mean at all. What I mean is people available on the ground to go and help local organisations to do this very complex work, to make these big changes. We need people with a capability to go out there and support them on that journey, as we had under the national service framework for mental health. An incredibly important part of the success of that was that there was a proper support system to help people locally to do it, and then there was proper accountability for whether they achieved it or not.

Chair

Thank you very much indeed for your time. You are very busy people. We will publish the transcript online in the next couple of days, and it goes up uncorrected. We will send you a copy. I am not sure when our report will be coming out. We have quite a lot to get through. We hope it will be by late July, with the possibility of September, but hopefully not that long. You are very welcome to stay for the next panel, if you wish, but we quite understand that you may have to go off to other things. We will send you a copy of the report once we have published it. Examination of witnesses

Witnesses

Professor Tim Kendall, Jon Rouse, Simon Stevens, and Chris Wormald.

Chair

Good afternoon. Welcome to our second panel on the issue of mental health services, on the back of the National Audit Office Report. I am delighted to welcome our witnesses. From my left to right we have Professor Tim Kendall, who is the national clinical director for mental health for NHS England. Welcome, Professor Kendall. We have Simon Stevens from NHS England. We have Chris Wormald in his first appearance as permanent secretary at the Department of Health. Jon Rouse, who comes regularly, is the director general for social care, local government and care partnerships at the Department of Health. It is fair to say that when we were preparing for this, we recognised that the Government, the Department and, indeed, NHS England are on quite a journey, in terms of trying to get parity for mental health and physical health. We know there are challenges, and we are hoping today to get out some of the baselines—where things are now, and where all of you think we are going to get to by 2020, to pick a figure at random. I will start with Simon Stevens. We will obviously come to you, Chris Wormald, on some of this. Simon Stevens, in the foreword to the NHS plan in 2014—the mental health strategy—you say, “Mental health problems are the largest single cause of disability, representing a quarter of the national burden of ill-health, and are the leading cause of sickness absence in the UK”, so you highlight some of the issues. This is in your foreword. Then you go on to say, “This makes it all the more indefensible that there is such a large ‘treatment gap’ with most people with mental health problems receiving no treatment and with severe funding restrictions compared with physical health services.” You rightly go on to highlight one of the consequences: “people with mental illness die on average 15-20 years earlier than other people—one of the greatest health inequalities in England.” You talk there, accurately and understandably, about the severe funding restrictions in mental health services. No one can disagree with that. I have done a quick add-up of the number of times you have been in front of us in the last six months. This is chapter 6 in how the NHS budget pans out. It is our sixth hearing since January, and our 10th since October, excluding social care hearings, which you have attended as well. Each time, we have had a series of budget issues. Let me give you a quick run through of some of those. Just last week, you talked about better care fund maths and real world maths. You acknowledged that there was an issue about funding there. NHS specialised services—this was about a month ago, in May this year—account for 13% of the total NHS budget. I am sure Chris Wormald is learning these figures in his new role. It costs about £43 billion a year to employ clinical staff across the NHS. I haven’t got the percentage figure to hand, but I’m sure you can do the maths. And then, of course, there was £1.8 billion of additional funding to bail out trusts for the last financial year. GP practices are 8% of NHS England’s budget. I think you agree with these figures. They are all from NAO and PAC Reports. Neurological services are 3.5% of spending. I could go on. That is just for the spending, not the waste, which we often look at as well. My question for you is this. Each time we see you, we are looking at a hugely pressurised bit of the budget. For mental health services, it is 12% of the budget. How on earth are we going to get to the point where it is affordable to have parity of mental healthcare with the current budget situation?

Simon Stevens

Well, I don’t think we can accept the current budget situation. We want to put more money into mental health services.

Chair

So where does it come from?

Simon Stevens

Well, the best buys that the independent Mental Health Taskforce, which I set up, and which reported in February, has laid out for us add up to an incremental spend of about £1 billion a year. If we are putting that money in, by 2020 that will buy us a series of improvements. Frankly, I regard that as the minimum necessary. If more funding were available, we would see a faster rate of progress on mental health services.

Chair

Is that money going to go in evenly over the next four years?

Simon Stevens

No, unfortunately it is not.

Chair

So it is like a hockey stick?

Simon Stevens

Yes, or a U shape. That is the profile of our spending review settlement. That means that a lot of the improvement, both by virtue of when the funding becomes available and because of the workforce—the need to expand and train up people to deliver these expanded services—is going to be coming online more like 2018-19, 2019-20 and 2020-21.

Mr Jackson

Why will it take that long?

Simon Stevens

Because that is the pace at which we are getting the extra funding. It is the pace at which the extra staff are getting trained.

Mr Jackson

The trouble is we always get jam tomorrow with you. You come along with a lot of emollient flannel—

Simon Stevens

I didn’t set the NHS budget; Parliament did.

Mr Jackson

Let me finish. And you set unrealistic targets. Incidentally, thank you for joining us, because I know you have been involved in pontificating on geopolitical issues like Brexit.

Simon Stevens

I am here once a week, as you know. In fact, I was here last week.

Chair

We are here to discuss mental health.

Mr Jackson

May I ask one particular question? You set a specific target on parity of esteem, and you have missed it.

Simon Stevens

What is the specific target you are referring to?

Mr Jackson

The target you set on the timeframe for achieving key objectives in terms of parity of esteem—I’m asking the questions, incidentally—and you have missed it. This Report shows—

Simon Stevens

It doesn’t show that at all.

Mr Jackson

Yes, it does. Don’t be argumentative, Mr Stevens.

Simon Stevens

I am replying to your assertion.

Chair

Mr Jackson, you can ask questions in a polite manner.

Mr Jackson

When I am asking a question, don’t argue.

Simon Stevens

Well, you are making assertions that I disagree with.

Mr Jackson

I’m inviting you to say why you missed the target. If you want to explain during the course of your answer—

Simon Stevens

I’m asking you which target you are referring to. If you can point to which target in the NAO Report you are talking about, I will of course respond.

Chair

Mr Jackson, we need to bear in mind that Mr Wormald from the Department of Health is here, and the Department, on behalf of the Government, has a responsibility for setting the targets.

Mr Jackson

Mr Stevens, you have presided over a record number of deficits in trusts, and today it was reported that you have presided over a significant increase in the remuneration of senior managers running those trusts. That is the issue we are looking at, in terms of management and what you’re delivering.

Chair

Very briefly. You have a right of reply, Mr Stevens.

Simon Stevens

Thank you. If you could specify which of the targets you believe has been missed per the NAO Report, of course I will describe what is going on, but I think you are making a more philosophical point, which is that we all have a shared ambition to get equal respect and equal treatment for people with mental health needs, compared with physical health needs. That goes under the rather jargonistic description of parity of esteem, which, frankly, I don’t really like, because I think most normal human beings wouldn’t know what on earth that means, whereas when you set it out in words of one syllable, they can see that there is a real problem that we have to address. We are seeking to get going on that. We have a clear set of service improvements that the independent Mental Health Taskforce has told us to get on with. That is what we are doing. But in terms of the funding profile for the NHS and the speed at which we can put extra money into the national health service, that is a function of the funding available to the NHS overall, and if the NHS had its way, of course we would do more faster, but we do not actually set the NHS’s budget.

Chair

I want to get back to the money. [Interruption.] Mr Jackson, I was in the middle of getting to the point about the budget. Let me get through the budget point and, as we discussed, I’ll bring you in at a later point. Going back to the budget, there is £10 billion, Mr Stevens, that you trumpet to us very often that you have secured from the Government to help shore up the NHS between now and 2020. This extra £1 billion that will be coming into the mental health services looks, on reading the figures, to be the mental health services’ share of that £10 billion, or is it additional funding? It does not look like additional funding from where we are sitting.

Simon Stevens

I don’t believe that that £1 billion is, or should be, the total increase in mental health services over the period.

Chair

Is it part of that £10 billion?

Simon Stevens

Of course it is. It is part of the extra available to the NHS, which in cash terms is from £101 billion up to £119 billion by 2020. As part of that general growth, there will be routine pressures in mental health services that will have to be funded and met by the mental health system. Over and above that, the independent taskforce has set out a series of very clear improvements that we want to see on people with severe mental health problems who are getting that onset in their teenage years—early intervention in psychosis, an expansion of psychological therapies more widely, perinatal, and a whole range of things.

Chair

We will come on to that, but I am concerned. We have laid out at some of the hearings when you have been here in front of us that we have 12% of the NHS budget going on mental health services. We know there is more need. One of the pre-witnesses suggested 23% of need. I wasn’t quite sure how that figure was worked out. Even if you just doubled it, that would be unsustainable, on the NHS’s current funding. You talked about real world maths last time you were in front of us. What is the real world maths that means we can achieve this?

Simon Stevens

I don’t think parity necessarily means that 23% of the NHS budget should be spent on mental health services.

Chair

I said I’m not sure about that.

Simon Stevens

In just the same way as we have a conversation about primary care and we say that 90% of patient contact applies in primary care, that doesn’t mean we should be spending 90% of the NHS budget on primary care.

Chair

No. Mr Stevens, you know that I don’t mean that. What I am saying is that if the budget is 12% at the moment, and we are nowhere near achieving just the aims that you have outlined, let alone the golden end of absolute parity—

Simon Stevens

I agree. I have explicitly commissioned the independent taskforce to do a soup-to-nuts study, laying it out bare, so as to make very explicit the baseline, the situation and the treatment gap that exists. We then have a series of very specific service improvement goals for which we hold ourselves accountable.

Chair

May we turn to figure 8 in the Report? I warn Chris Wormald that I am coming to him next. Figure 8 on page 31, part two of the Report, refers to the cost of the early targets in IAPT—improving access to psychological therapies—early intervention in psychosis, which you just mentioned, and liaison psychiatry services, which is psychiatric treatment in hospital given to those who come into hospital for other reasons. There is a concern that the published figures are an underestimate as a baseline. Are you confident that those figures are accurate? If there is an underestimate, a percentage of any money going in will be eaten up by the gap between that underestimate and the actual need.

Simon Stevens

The substantive point is that we are now measuring—

Chair

That’s a good start.

Simon Stevens

On the IAPT, notwithstanding Mr Jackson’s pessimism, this is an area where there has been dramatic improvement since 2008, when the programme was first introduced. Over that period, 3.5 million people have had access to psychological therapies, and indeed, the speed at which people are getting treated and the success of their treatment has improved quite substantially even since the NAO had access to the 2014–15 figures. On the access to IAPT services, we are doing very well, but we want to go even further from 15% access to 25%, and that is one of the funded propositions in the independent taskforce. On the early intervention for psychosis, there is a very strong evidence base that that is not only good for individuals but will improve the rest of their life, and potentially save money in other parts of the health service. In terms of ensuring the waiting time standards—the first two waiting time standards that the NHS has introduced in mental health—we have now got the provisional data collection on that, against the target waiting time that 50% of people should be seen within two weeks. The provisional figures for March show that that was 64%. The key to this will be to make sure that the treatment that they are actually getting within that rapid timetable is the full NICE-approved package. Rather than a series of self-assessments, we are getting the Royal College of Psychiatrists to oversee the package of care that is being delivered against that standard to make sure that it is the full whack.

Chair

To return to my question about the baseline, you are working to getting—

Simon Stevens

The baseline estimates that were done in September 2014 by the DH were what they said: estimates. In the real world, the question is, are patients getting treatment within the waiting time standards that we have now set, and is that treatment of the approved quality?

Chair

My point is, just to repeat—

Simon Stevens

The answer is yes.

Chair

Right. If the estimates are low, we will have a problem of attrition, in terms of the extra money going in.

Simon Stevens

The point I am trying to make is that these standards are already happening. These are new waiting time standards that have come on track from April of this year, and so their delivery is being implemented as part of what the NHS is doing this year.

Chair

One of my colleagues will consider that further, but may I go back to the funding issue straight? According to evidence to us from NHS providers, only 52% said that they had reported an increase in funding in 2015. We have had a lot of evidence in the debate about ring-fencing or not ring-fencing, but if only about half of providers have said that they are getting an increase in funding, where is the money going to improve mental health services? Is it actually getting to where it is supposed to go?

Simon Stevens

The honest answer to the question is that it is a combination; in some areas, the money is not getting through and in others the money is going to other parts of the mental health system, but not necessarily to the NHS mental health trust in the local area.

Chair

You don’t know really, do you?

Simon Stevens

We have attempted to do a reconciliation for every CCG, as to what their out-turn spending was last year compared with the increased goal that they set. We are doing the same again this year and will move over to open-book accounting, so they will have to be able to show their local mental health trust and everybody else where the money has gone. If I may, I will explain a little more about why some of the increases in mental health spending might not be with the local mental health trust. One example is that we want to expand what is called liaison psychiatry, which is services for mental health in A&E departments of acute hospitals. Often that will be provided by a mental health trust, but not necessarily. It might be provided direct by the acute hospital itself. That extra spending therefore will not show up in a mental health trust’s account. Secondly, we are committed to expanding the number of therapists and psychologists in general practices, helping GPs deal with the workload of patients who present in primary care. That may or may not show up as revenue to the local mental health trust. Thirdly—

Chair

No, I am going to stop you there.

Simon Stevens

It is quite a long list of ways in which investment might not show up in the local mental health trust.

Chair

Yes, absolutely. I don’t want the long list. Mr Stevens, my point is not about the long list. I hear exactly what you are saying about bits of money going to different places, but let us be clear: according to the providers themselves, only around half have reported an increase in funding in 2015.

Simon Stevens

The secondary mental health trusts, yes, but that is not the same as the mental health provider sector in the round. One of the other issues, by the way, is that there has been a steady shift in the proportion of mental health funding and usage in NHS trusts, compared to the independent sector. The independent sector of mental health providers has reported increases of around 4% a year for the last three years. One thing we have got to do, and are now doing, is to take a very hard look at those patient flows and that funding growth to make sure we are getting good value from that expenditure as well.

Chair

I will bring in Chris Wormald in a moment, but the Comptroller and Auditor General first.

Amyas Morse

Just to clarify, this information is from NHS providers as a whole—that is how they represent themselves.

Simon Stevens

Yes, but that is not the independent sector and it is not expenditure in general practice. It is not improvements in—

Amyas Morse

I am not trying to say it is, but it is a moderately significant proportion.

Simon Stevens

It is. As I have said, the honest answer is that it is both parts of this. That is absolutely a fair reflection in some parts of the country, where mental health trusts have not seen the investment we would have wanted. In other parts of the country, some of that investment has been going into other parts of the system.

Chair

Notwithstanding the fact that it goes to other parts of the system, I am surprised that that many had none. That is the point. You agree that that is possible. Well, that is what they have told us.

Simon Stevens

Yes. I do think that is possible

Chair

That is not very good from our perspective. Mr Wormald, on the money that is available, you are responsible, and the Secretary of State has a duty to address mental health in the Act. It is in the NHS mandate, which is the bit that Simon Stevens is responsible for delivering. Is there going to be enough money to deliver this by 2021?

Chris Wormald

I think Simon described the situation exactly as it is.

Chair

Yes or no?

Chris Wormald

Well, we agree with NHS England that the additional investment being made, prioritised in the way that is described in the five-year plan, ought to be able to achieve the outcomes that Simon is describing. That is not to say that money is not tight—of course it is—but in terms of, “Is there a forward plan here, and are there resources that go with that forward plan?” the answer is yes.

Chair

We are glad that there is a forward plan, but without the money—as I outlined just now—every bit of the budget we see for the NHS is under stress. Efficiency savings are being demanded of hospitals and we have the bail-out of the acute trusts, with the promise that efficiency savings are coming down the line. There is nothing to guarantee that mental health services will be protected from that, is there?

Chris Wormald

Just as a matter of fact, we have not ring-fenced the resources for mental health. That was one of the questions I asked when I arrived in this area, and the answer that I was given was extremely convincing. You have to look at facts such as the fact that 30% of people who have long-term physical conditions also have mental health issues. You have to think about the behaviours we are trying to incentivise, such as people spending around the patient, as opposed to around the service. All a ring fence does at local level is distort spending, and if we want—as I am sure we all do—GPs, clinicians and others to think about what the right package of care is for this patient in the round, taking in both their mental and physical health issues, what you don’t want is their clinical priorities distorted by a ring fence. So, although a ring fence is a simple solution and makes a good and easy story to tell, in terms of how we promote the kinds of practice that we are looking for—the kind of way that the budget works and the way that Simon has described—that does seem to make sense.

Chair

I will bring in Karin Smyth in a moment, but what you seem to be saying there is that not ring-fencing allows for a joined-up service for the patient. However, how can you at the Department be sure, given this is a major political priority—you are responsible for helping to do that on behalf of your Secretary of State—because you can’t track the data, that it’s not the first thing that gets cut when there is a pressure on budgets?

Chris Wormald

Well, all the things—I did actually think, and I should have said this at the beginning, that the NAO Report gave a very fair assessment of where we are and what we need to do next. So I don’t think that anyone is denying that there are considerable amounts more to do to achieve what we need to, but I also agreed with your pre-panel evidence that we’ve got a better opportunity to do that than we have had for quite some time. Now, if we’re not going to use primitive methods such as ring fencing to track what we achieve, it is the set of policies that we have set out. Transparency in data is incredibly important. So that is all the work that NHS England has done to track spending and track it much better going forward than we have historically. So we will be able to tell what is spent where. That is incredibly important. The transparency that has been brought by the local transformation plans, not just for what the NHS spends but for what local partners spend and how they do so, is extremely important. You had a debate with your pre-panel about targets. I think targets in this case, when you are trying to change behaviour, can be important. I think there can be a debate about what those targets are, but clearly tracking against the actual outcomes is extremely important. The other point that also came out of your pre-panel—

Chair

We heard it too. We don’t need the whole pre-panel repeated, Mr Wormald.

Chris Wormald

Sorry, but I wanted to emphasise the point that thinking about mental health is being built firmly into everything that the NHS does: in the sustainability and transformation plans; and in everyone’s thinking around health reform and efficiencies. That is the other piece of the jigsaw. When you put all that together—if you have transparency, good data, targets that you can track and everyone working on it, that does seem to me to—

Chair

Mr Wormald, I have been indulgent, because this is your first outing, of your giving a full read-out of all the things that you are going to be doing, but we need to stick to answering questions. Just for interest for witnesses, I read through the last transcript. We are getting shorter in our questions, but your answers aren’t getting short. Now we’re not asking you to give bite-sized pieces—we do need information—but we do have a report we’re discussing. May I bring in Karin Smyth and then I will bring in David Mowat?

Karin Smyth

This is a baseline report; we’re very keen to get a good baseline, to be able to revisit some of this. I just want to track back to where we are tracking the money. I think, Mr Stevens, what you said was that you were looking to have open-book reporting from CCGs on what they are getting and therefore on what they are spending, and what they get for that, which would allow us to track the money better than perhaps just looking at some providers. Is that right?

Simon Stevens

Yes.

Karin Smyth

When would we be able to see the results of that?

Simon Stevens

During this year—during ’16-17. And related to that, we have commissioned an independent panel to assess the extent to which every CCG is using that money appropriately and delivering on the improvements that are in the independent taskforce. That panel is being chaired by Paul Farmer, the chief executive of Mind, who was the principal leader of the independent taskforce. So we will be publishing CCG ratings. Everybody else will be able to see how their CCG is doing on mental health and on the improvements—

Karin Smyth

So when we look at this in the future with the NAO—whenever this is relooked at—to form our next look at how this is progressing, we would be able to use that to start tracing the taxpayer’s pound.

Simon Stevens

That plus the programme budgets, which will be more timely as a result of the changes we are making.

Chair

When do you estimate—between you, or maybe Professor Kendall—that we will actually be able to see real outcomes? Obviously, there is a time lag in people getting treatment. You are going to look at the benefits and cost savings to the NHS of early intervention. What is the timeframe for assessing the cost-benefits once you have got this data?

Simon Stevens

I will bring Tim Kendall in in a moment—or rather Claire Murdoch, who is our national director for mental health and who I have appointed to lead the implementation of the taskforce. Claire is the chief executive of one of the largest mental health trusts and is one of the most respected operational leaders in mental health in the country. Next month she will be publishing the implementation plan that goes behind the taskforce recommendations. That will set out the phasing of the outcomes improvement and the services that we will put in place, which we will then be able to track against.

Chair

So is there an idea of how many years it will take?

Simon Stevens

Without making this a long answer, looking at the improvements that the taskforce is setting out for us, some of them are phased—between 15% and 25% expansion for IAPT over five years. Some of them—such as the early intervention for psychosis—we are getting going on right now, so we will see results soon.

Stephen Phillips

Sorry, Mr Stevens, but that is a very long answer. It is a very simple question: when will we start to see an improvement in outcomes? Give us a date.

Simon Stevens

We are seeing improvement in outcomes this year from the expansions that are in place this year. The timing for each of the individual improvement goals set in the taskforce will vary depending on the nature of the programme.

Chair

So we are starting some this year, and ongoing—

Simon Stevens

Yes, and Claire Murdoch’s implementation programme will lay that out—what the phasing of this looks like.

Chair

Ms Smyth highlighted what we will be able to ask next time you are in front of us. So let us say that in a year’s time you are here again—it may be before then, who knows?—we will be able to have some clear data about what the investment has actually achieved.

Simon Stevens

Yes, exactly, so for example—

Chair

I don’t need examples—that is fine.

David Mowat

I guess what bothers me about this is slightly different. There are two ways of establishing how we spend money. One is a top-down approach: Parliament passes a law—parity of esteem—and we get as much money into the system as we can afford, and then you spend it on that. The other is more bottom-up, which in a way was what the reorganisation was about—the CCGs are responsible for establishing priorities and everything else. In a sense, some of the evidence that you have given today is saying that when you have given money to the CCGs, they have actually spent it on something different. It has not been ring-fenced. One of you used the phrase “reconciliation of what they spend it on”; you are going to rate CCGs on what they are spending it on. What I am getting to is that this implies to me that the CCGs were presumably acting in good faith and are aware of the priorities—

Chris Wormald

I don’t think that is quite what we are saying. I would characterise—

David Mowat

Can I finish? A question I would like you to answer is why the CCG priorities are different to yours. That is what I was getting to.

Chris Wormald

I am sure Simon will give an answer as well. As a fresh reader, the model of reform here is local decision making within a clear national framework. We set a national framework for inspection through what NHS England does and all the other things we have been describing, but then we want sensible people locally taking sensible decisions about the actual issues in that particular area. We want them taking the decisions within a framework, but we want them to be responding flexibly. So we would expect to see some difference, and that is what plays out. The question, which is what we have just been debating, is whether we have the right sources of information to know that that is all being done properly. That is what Simon has been describing.

Simon Stevens

Yes. I think the money argument is a proxy for the availability of high-quality services and the outcomes they have. The national service framework for mental health was introduced in the early 2000s, when we did have clarity about some improvements that we wanted to see—or indeed 25 years ago when I started working in mental health. My first job in the NHS was managing a large psychiatric hospital outside Newcastle and it was clear that the programme of work there was to re-provide services in community settings. We have had a period of time in recent years when we have not actually been very precise about what the improvement goals for mental health look like. Now we are being precise, based on the recommendations of the taskforce, and we want to hold people to account for delivering those improvements. The money is a means to an end; it is not an end in its own right. Are we being more prescriptive about delivery against the things in the taskforce? The answer is yes, we are going to be. That does not fetter people’s discretion in a whole set of other parts of mental health services—or, indeed, other parts of the NHS—but if you are a pregnant mum or a new mum and you’ve got severe perinatal mental health problems, you should have access to specialised services. If only 12,000 mums out of 42,000 in the country have that access this year, we want to change that, so everywhere needs to have those specialised services.

David Mowat

So what you’re saying is that one of the reasons why the CCGs are not spending their money more as you would have liked them to is that they do not have the availability of stuff to spend it on, because there is a supply/demand thing—I think that’s what you have just said.

Simon Stevens

That’s right: that is one reason. There are other legitimate reasons as well. For example, they might be in deficit or they might already be a relatively high spender, in terms of their overall portfolio. As we have been looking at these so-called parity of esteem funding increases, we have been going down to every CCG, saying, basically, “Are you in deficit? Are you already a high spender?” Where there’s—

David Mowat

What I’m getting to is that everybody can agree that parity of esteem is a good thing. I would have thought that was very easy to agree, or very close to it.

Simon Stevens

As a broad philosophical goal.

David Mowat

Except that it’s a statement of relative priorities. Where you perhaps get into more difficulty with a statement of relative priorities is when you don’t say which things you are giving less priority to as a consequence, which, given that you are resource-constrained—which is fair enough—must be the case. I always think that a strategy that doesn’t point out what we are not doing as a consequence of what we are doing more of is slightly dishonest. I don’t know whether you want to comment on that or say which areas you think should be being replaced by this extra emphasis on mental health.

Simon Stevens

I would be happy to. I think part of the problem in mental health services is that across the NHS it has been the squeaky wheel that has got the oil. If you think about the large cost overruns that Mr Jackson was alluding to earlier in acute hospitals, there are understandable reasons for them, but they have had the effect of crowding out what would have been investment in mental health services and primary care. The reality is that this year we are going to have to have a reset on what some of the spending looks like in acute hospitals, in order to free up some of the investment we need to make in mental health.

David Mowat

Okay, so another way of putting that might be that—I don’t know—NICE might have less flexibility in authorising a particular drug because it has been decided, by whoever decides these matters, that mental health is the thing that we are really going to focus on. The only reason I say that is that it tends to put decisions into context, because then other people might say, “Well, how do we decide those things and how do we prioritise that?” To make it an honest discussion we should do it in both directions.

Simon Stevens

Yes, that’s right, and I think that’s a very important point to make, including for a lot of the conversations we have when I’m before you. The Chair pointed out the range of topics earlier, and by definition every theme that is reviewed is important. Everyone could benefit from improvement, but the reality is that, if you are a local CCG or the NHS nationally, we are having to make choices all the time and a lot of those choices are very difficult.

Chair

Talking about that choice, one of the challenges with the data being far less than perfect—a bit of a running theme, I know, but particularly so in this area—is what you will do if the need on the ground outstrips this budget, which is not even going to be in place until the end of this Parliament.

Simon Stevens

The need on the ground already outstrips the budget and will still outstrip even the expanded budget in 2020. Let’s be completely frank about this: this does not give us—

Chair

This is about the fourth time—or maybe even the sixth—you’ve said this to us this year.

Simon Stevens

I’m known for my frankness and I’m happy to continue to be so.

Chair

Or maybe it’s a bid for more money from Government.

Simon Stevens

No, I’m simply making the point that, even if you look at, say, the very important area of children and young people’s mental health services, even the important extra investment that is going in there may mean that, instead of being able to respond to perhaps one in four children who might be defined as having a mental health need, we can improve that, such that we are supporting one in three. That will be hugely welcome for the 70,000 extra children who are getting those services, but that most clearly is not mission accomplished.

Chris Wormald

If I can add, I actually think the Government has been very clear on what the extra investment is and what level of efficiency saving it is expecting to see across the health service. So in terms of what needs to be stopped to make space for new things, it is all in that efficiency piece, and the Government have been very specific around things like agency nurses, etc, about things that should stop.

Chair

Mr Wormald, I know you are new to the Department, but we get a bit weary about the agency point, because, as Mr Mowat very ably pointed out when we first discussed this, and several times since, it is not about the rate of pay; it is about the volume. That is about shortages—

Chris Wormald

I take the point that I should not use that example.

Chair

Also the amount of money that spends is not going to solve holes in the NHS budget. Also, on the efficiency savings we have got, we are sceptical on some of those. Can I just be clear, actually, on efficiency savings: there isn’t an NHS Transformation element to mental health services? Am I right in thinking it is not part of that programme?

Simon Stevens

Some of the vanguards, the vanguard programme that has been established, do have a mental health element, because partly we are trying to—

Chair

But it is not a wholesale thing?

Simon Stevens

It is not a separate, free-standing thing; but, in terms of the funding allocations for the next five years—and when Claire Murdoch publishes the implementation plan you will see this laid out—some of the transformation funding available in subsequent years is being specifically earmarked to implement the mental health taskforce recommendations.

Chair

So there isn’t a transformation fund for mental health, but it will take a bit of the little bit? How much, do you know, roughly—ball park? Do you know?

Simon Stevens

For some of the programmes—would you allow me to give an example?

Chair

Yes, I will; this an answer where we might want the information.

Simon Stevens

If you take liaison psychiatry that we discussed—i.e. psychiatrists and mental health teams in A and E departments—the full version of that model involves about 25 whole-time equivalent staff. At the moment, 10% or slightly under—the NAO had it at 7%, I think, but it is probably a bit more than that, 10%, now—of A and Es have that full, core 24 liaison psychiatry. We want to get that to at least half by 2020. That is going to cost, we estimate, around another £120 million a year by 2020. We are phasing the build-up of that, some of which—in fact, most of that—is going to therefore come out of the nationally held transformation fund, because it is only one in two A and Es. We cannot just put that into general allocations. If you take the crisis home response teams which are required—the community health teams that can respond 24/7 when people have mental health crises—that, we estimate, is going to cost at least another £150 million by 2020; and all of that money will be in CCG allocations, because that has got to happen everywhere.

Chair

So it is quite a chunk of the extra budget already. I am going to bring in the Comptroller and Auditor General and I have got a couple of points before I hand over to John Pugh.

Amyas Morse

Just to make sure I have got this clear, of the efficiency savings, how much of the funding for mental health services is dependent on realising efficiency savings in the rest of the NHS? And if they were not realised, or they just went to decrease the deficits in trusts, what would happen then? Would the amount of money spent on mental health programmes be reduced?

Simon Stevens

Of the increases available to the NHS over the next five years this £1 billion is going to be earmarked to implement the taskforce recommendations, and that is £1 billion notwithstanding what is going on in the rest of the portfolio—with two caveats. First, mental health services need to make efficiencies over this time period just like all the rest of our cost base, and the assumption is a 2% efficiency. There are opportunities, even in mental health services, despite the fact that they are stretched—and Tim Kendall gives some very practical examples of how in his trust in Sheffield they have been obtained. Over and above that, were there to be a continuing unbudgeted overspend in the acute sector, or were there to be any substantial economic shock to the financial prospects of the national health service over the next several years, that would obviously call for a rethink.

Amyas Morse

So there is a dependency? You are saying there is a potential dependency between this?

Simon Stevens

No, I am saying we have an earmarked £1 billion for this and we think that is eminently deliverable. It is not £1 billion that has been recycled out of savings from other parts of the system.

Professor Kendall

There are undoubtedly savings to be made.

Amyas Morse

You did leave yourself an exit hole there, if you don’t mind me saying; I’m sorry.

Chair

That’s exactly what I was thinking, Mr Stevens.

Amyas Morse

You left yourself a burrow to go down, there, by saying, “But we might have to have a rethink.”

Chair

That’s what I heard, very clearly; that you are sitting next to the Permanent Secretary saying, “We might have to have more money.”

Simon Stevens

No, I just read news in this morning’s papers of the possibility of budget cuts for the national health service. That is all I was referring to. I was not referring to the base case, which we are all working to.

Chris Wormald

Just as a statement of fact, of course mental health spending is a part of overall NHS spending, and if overall NHS spending changes, mental health will be affected. I don’t think that is a controversial thing to say.

Chair

Who knows what will happen in the next week that might make a difference, or indeed in the next year or few? I want to clarify one point, and then I have a second question, before handing over to John Pugh. Paragraph 2.18 of the NAO Report, in relation to figure 8, says: “The estimate in the Department’s 2014 impact assessment was that the cost”—of meeting the new access and waiting times standards—“would be £160 million a year more than the estimated £663 million that clinical commissioning groups spent in 2014-15 on these services.” I’m not sure who wants to answer this, but have you updated that estimate since 2014?

Jon Rouse

This relates back to the conversation we were having earlier about figure 8 with the pre-witnesses. The starting point is that this was an estimate done in 2014, through a proper impact assessment, looking at investment requirements and potential benefits flowing back. We came to the conclusion in terms of the first three things we were trying to do—IAPT, EIP and crisis care liaison—that the initial input for the first two years, 2014-15 and 2015-16, was actually £120 million. That was what was invested in that period. Clearly, that preceded the spending review, the taskforce report, the further analysis being done, the stretching of ambitions and the taking on of some new ambitions as well. To a certain extent, this is a bit of an insight into the past, because we are now in—

Chair

That is a lovely phrase. You mean it is an underestimate for the current one?

Jon Rouse

It is, because we are now in 2016-17 and we have reset through the taskforce report.

Chair

You have reset it. Can you just be clear about what the figure would be today, in 2016?

Jon Rouse

We have calculated, within the £1 billion, the extra requirement for what we are going to do next, including the expansion of IAPT, with the further increase through to 2020-21 and EIP through to 60% rather than 50%; and the work that Simon has described around liaison psychiatry, home treatment teams, eating disorders and perinatal. We have calculated what we think is the affordable level of investment required, taking into account efficiencies that may be gained. That is essentially where that £1 billion comes from. It is built up from those component parts.

Chair

We will be coming back to this. I may come back on efficiencies later, but Mr Wormald and Mr Stevens, what proportion of the NHS budget should be being spent on mental health services, given that we know not enough is being spent on it at the moment? What proportion, ultimately, is the aim?

Simon Stevens

I don’t think it would be sensible to set a proportion in that way for the reasons that Mr Mowat gave, which I agree with, in relation to this question. What we should be doing is targeting investment on the areas that the taskforce has marked our card with. They have done a clear evidence review of the best buys for mental health improvement over the next five years. That is what we want to deliver. Over and above that, there will be other changes and other investments that CCGs locally will want to determine. The percentage will be the combined effect of all those things.

Chair

Okay. I am going to hand over to John Pugh, who I know will pick this up, but the key thing is this: we heard from previous witnesses that money spent up front saves money down the line. Chris Wormald, how are you going to be measuring that? Over what timeframe will you measure it, and how will you factor that into the funding decisions for this really important area?

Chris Wormald

I might ask Jon to give you a more detailed answer. There is, I gather, quite a lot of evidence—in answer to Mr Bacon’s original question—about how much you save for specific interventions, which is not the same as whether there is a pound rate for every £1 spent. We can send the Committee—

Mr Bacon

I presume it varies depending on—

Chris Wormald

As I understand it, it varies treatment to treatment and it varies, crucially, as with all spend-to-save schemes, on whether it is done well. We have all seen a spend-to-save scheme where you get the spend but not the save. So we are quite happy to send you the research evidence—

Chair

John Rouse can answer that, and I think Karin Smyth wanted to come in on this point.

Jon Rouse

I just want to make the quick point that the prioritisation we have done around which conditions to tackle and which interventions to put extra funding into has been partly driven by that cost-benefit analysis. In a sense, we are backing the NICE-approved interventions, which we know—based on the literature reviews, the evidence and the studies that have been done—give us the best bang for our buck.

Simon Stevens

We have actually published that evidence here, the Committee might like to know: “Priorities for mental health: Economic report for the NHS England Mental Health Taskforce”. It’s all there, setting it out.

Chair

I think one of the previous witnesses showed us that as well. We will get a hold of that.

Karin Smyth

On this point, I asked the pre-panel about financial incentives for the various people involved in supporting people with mental health problems, and if they were correct. Mr Rouse and Mr Stevens, I would be interested if you would give a view about financial incentives for the different parties involved, and whether there are any plans to look at those or change them.

Jon Rouse

That’s a good question. One of the things that has hamstrung us over the years around mental health is that so much of the spend is hidden within block contracts. I think one of the pre-witnesses actually said that it is very difficult to make judgments about whether that money is being well spent if you are getting a fixed sum almost regardless of how many people you are treating and whether you are treating them well. That is one of the reasons why, over the last two years, we have put so much effort, behind the scenes, into reforming the mental health data set and changing some fundamentals about it. One is that, going forward, we will be building up the data from the individual episodes of care, so that when somebody is referred, that referral becomes a new episode that the data attaches to. The reason why this is so important is that you begin to be able to relate the money being spent to the outcomes being achieved, particularly as we are now using a new data collection mechanism called SNOMED. The important thing is that it is a consistent approach to how you capture data about outcomes. Once you can start relating data on outcomes to spend, you can start properly measuring value for money. There is one other critical thing that NHS England and NHS Improvement are doing that you need to complete the circuit, and that is to do away with block contracts and put in place a choice between two different options. Either you have a proper capitated budget, where you as a provider are responsible for that population with spending transparency, or you attach the funding to the episodes of care themselves.

John Pugh

I will come back to that last point a bit later. Can you regard this as not an inquisition but more of a counselling session where we get to the bottom of your problems?

Chair

I don’t think Dr Pugh is a medical doctor, but he’s got a good bedside manner.

John Pugh

Group therapy, maybe. Clearly, we all share the same laudable ambitions—parity of esteem and so on—and you are using two devices to improve how things look. One is to add resources. We can argue about the right level of resources; I think it is probably impossible to say what the right level of resource is. If you go back to the 1950s, I think we were spending 20% of the NHS budget, but we were warehousing a lot of people in doing so. In terms of looking at the targets, everybody knows the targets are distorting and lead to gaming and people incentivising the wrong thing. We have had a sense of that in some of the comments made by the pre-panel. I get the impression that you share that perception, and that at some point in time, having employed these targets, you are going to evaluate what the targets are actually doing in terms of overall outcome and performance. Am I correct in thinking that?

Simon Stevens

Yes, I think that’s right, although we are 25 years on from when the NHS first introduced waiting times targets for routine surgery—for having your hip or knee or cataract done. The way that was done, as you know, was layered in over time, so that when they were first introduced, it was two years maximum wait to have your cataract out. Then it was brought down to 18 months, then six months and then it included your outpatient appointment as well. Now the average wait has fallen from 18 months to a maximum of 18 weeks, with a median wait of 10 weeks. That has been a journey that has taken place over a long time. I think there would be a benefit in introducing waiting time standards for mental health services. We have done that for the first two areas this year, as you know. We have talked about IAPT and the early intervention in psychosis service. We want to do the same for eating disorder services, and then layer those into a broader range of services because it helps to highlight the gap between need and treatment availability, it helps to focus management and funding efforts, and as we do that, it also improves patient outcomes.

John Pugh

I am not arguing against targets full stop. I am arguing for a sensible review of what targets are doing. We had a piece of evidence from the British Psychoanalytic Council, which represents 10,000 psychotherapists. Their evidence suggests that IAPT therapies, simply because they are marked for in a sense, are chosen in circumstances where they might not be the best clinical options. They are already pointing to an instance, as it were, where what people are being marked for, assessed for and targeting can divert clinical practice. I am not saying that that is a cast iron case against doing it. I am just saying that there has to be some review of it.

Simon Stevens

The evidence base for IAPT is incredibly strong, not just out of the research literature but also from the 3.5 million people who have benefited since the programme has been introduced. It is the strength of that evidence base that is leading us to want to expand by another 600,000 people, who are getting access to these services over the next five years. There is a question within IAPT as to which is the right psychological therapy, and there is a debate among some practitioners about the pre-eminence of cognitive behavioural therapy versus other therapeutic modalities. I think that only 17% of people who received IAPT services said that they did not get the therapy of choice that they wanted, but NICE has set out a range of different therapies within the broad remit of IAPT and it is that broad range that should be made available.

John Pugh

Specifically on that, in their submission they say that 85.1% of people referred to the IAPT programme are not moving to recovery from their mental health problems. That conflicts with the evidence in the NAO Report. Do I take it that your view is that they are just wrong and this needs to be corrected?

Simon Stevens

On the recovery rate, yes. The recovery rate for February 2016 was 49% against a goal of 50%. In the NAO Report for the year for which they had the data, 2014-15, it was a 45% recovery rate. It is now 49% against a 50% goal. That, together with improved access and speed of treatment—86% are now getting seen within six weeks compared with 79% in 2014—actually, this programme is not only working, but getting better.

John Pugh

Broadly, you are saying that you are confident with the targets you have chosen, but you have not said that you are going to review them further down the line to see what effects they are having on overall performance, patient satisfaction and whatever other indices you want. Meeting your target is a proxy for people being cured and made better.

Simon Stevens

On IAPT, we have had strong, independent advice over multiple years from 2008 onwards from NICE and the research unit at Oxford. Lord Layard has been a strong champion of this. There is strong support for the IAPT programme but it is not the be all and end all. It is an important part of what the therapeutic arsenal should be. But the reason that we chose early intervention for psychosis as the other waiting time standard that we were going to introduce is because it is at the severe end of the spectrum, if you like. Three quarters of mental health problems first take effect before people are in their early to mid-20s, so that will benefit people right at the start of their use of mental health services.

Chris Wormald

May I add to that? There is a lot of literature about targets that points out all the upsides and downsides that you have described. One thing that is always written is that if you are going to have targets, they need to be clear and consistent over a reasonable period of time. People get rightly irritated when we change target systems all the time. The goalposts move and you cannot track, year to year, measures because—

John Pugh

I am not saying that you change them all the time. I am saying that you review them.

Chris Wormald

Do you have to keep an eye on the effects of your target? Of course you do. Do you want to be clear and consistent over a reasonable period of time? Yes. The point I was making earlier was not that targets are the only game in town. If you had an entirely target-drive system, you would have many of the risks you have described, but you have a lot here: you have what NHS England is doing to review across the board; you have what CQC does. Targets are part of a wider package that is about incentivising the behaviour we want to see.

John Pugh

May I bring Mr Rouse back in, particularly in connection with the discussion about funding incentives to targets. Obviously, this would not apply in physical medicine, but if you are going to be incentivised for, say, recovery, in the psychiatric world that can be a subjective judgment. If you are financially incentivised in that way, it could have a distorting effect on the performance of different trusts and different providers, and ultimately on patients. Is that taken into the equation in your modelling?

Jon Rouse

Yes. Nobody is suggesting we attach financial incentives to recovery in that way because of the distorting effects that you have pointed out. What you should do, of course, is to look at whether you are getting value for money overall from your investment in particular modalities and particular programmes, or whether one CCG is using its money more wisely than another, or one provider is performing better than another. That’s the type of analysis you want to do to calibrate the programme. So if it is working particularly well in one area compared with another, transfer that practice from one area to the other. The problem is that we have not had good enough data up to this point to be able to make those judgments and we are going to in the future.

John Pugh

What an excellent lead into my next question, which is about data.

Simon Stevens

Would you willing for Professor Kendall to come in because he is a practising psychiatrist, medical director of the Mental Health trust and has led the NICE evidence reviews on many of the treatments that work? So I think he will have something to offer.

John Pugh

Excellent. Briefly, Professor Kendall.

Professor Kendall

It is worth saying that alongside the introduction of access and waiting times, quality improvement networks are being used. All trusts will be required to join quality improvement networks where they will be able to compare outcomes that are specified for each particular waiting time, so over time we will be able to see pretty clearly what the impact is of introducing the money and introducing targeted waiting times. I am pretty confident that over time we will get a national improvement, and if we don’t, we’ll know.

John Pugh

And you will be led by the evidence. Good. On the data question, figure 4 is broad brush and inexact. We simply don’t have good data not on how much we spend globally on mental health but on the individual conditions and so on. If that was the case with physical health, we would find it astonishing. We would want a breakdown. We wouldn’t want half the budget to cover “other physical conditions”. We would want something a lot more sophisticated. What steps are being put in train to improve the flow of diagnostic data through the system, if there are any?

Simon Stevens

From a clinician’s point of view? We will move on to the HSCIC stuff in a moment, but from the other end of the telescope and treating patients—

Professor Kendall

Give us the question?