Public Accounts Committee
Oral evidence: Progress in improving mental health services, HC 1000
Thursday 20 April 2023
Ordered by the House of Commons to be published on 20 April 2023.
Members present: Dame Meg Hillier (Chair); Olivia Blake; Dan Carden; Sir Geoffrey Clifton-Brown; Mrs Flick Drummond; Mr Louie French; Anne Marie Morris; Sarah Olney.
Abdool Kara, Executive Director, National Audit Office; Adrian Jenner, Director of Parliamentary Relations, NAO; Natalie Low, Director, NAO; and Marius Gallaher, Alternate Treasury Officer of Accounts, HM Treasury, were in attendance.
Questions 64 - 183
Witnesses
I: Sir Chris Wormald, Permanent Secretary, Department of Health and Social Care; Matthew Style, Director General NHS Policy and Performance, DHSC; Amanda Pritchard, Chief Executive, NHS England; Claire Murdoch, National Lead for Mental Health, NHS England; and Professor Sir Stephen Powis, National Medical Director for England, NHS England.
Report by the Comptroller and Auditor General
Progress in improving mental health services in England
(HC 1082, Session 2022-23)
Examination of witnesses
Witnesses: Sir Chris Wormald, Matthew Style, Amanda Pritchard, Claire Murdoch and Professor Sir Stephen Powis.
Chair: Welcome to the Public Accounts Committee on Thursday 20 April 2023. Today, we have our second session on mental health services in England, and we have witnesses from the Department and NHS England. We had a very useful session on Monday with people dealing with these issues on the frontline. Of course, the Government have a target to have parity between mental and physical health services, which is a huge challenge for the system as a whole. We know it is not an easy task, and we want to tease out from our witnesses today what progress is being made, where the challenges still remain, and whether the goals that have been set are realistic, given the current challenges in the system.
I would like to introduce our witnesses. We have, of course, Chris Wormald, the permanent secretary at the Department of Health and Social Care; and Amanda Pritchard, who is the chief executive of NHS England. They are joined by Matthew Style from the Department, who leads as director general for NHS policy and performance; Professor Sir Stephen Powis, who is national medical director for England at NHS England; and Claire Murdoch, who is the national lead for mental health at NHS England. A very warm welcome to you.
This is a hugely important issue. It is big in all our in-trays as MPs, and it is of course important to a lot of people up and down the country. Before we go into anything else, I would like to ask a couple of members to make declarations of interest.
Olivia Blake: I would like to declare an interest. Before being an MP, I was a non-executive director of a mental health and learning disability trust. I am also a member of the APPG on eating disorders.
Dan Carden: I would like to declare that I chair the drugs, alcohol and justice all-party group, and I serve as a director of a not-for-profit organisation, Addiction Recovery Now.
Chair: Before we go into the main session, we just wanted to catch up with the situation with the doctors’ strike, and of course the looming nurses’ strike. I will ask the deputy Chair, Sir Geoffrey Clifton-Brown, to kick off.
Q64 Sir Geoffrey Clifton-Brown: Good morning, everybody. I will start with you, Amanda Pritchard. We are very grateful to the professor for coming here, particularly to talk about the clinical effects of the various strikes. I will start with Amanda on the mechanism of the nurses’ strike and the junior doctors’ strike. Could you give us an update on how you see each of them being settled? I accept that this is a negotiation and that there are rates to be discussed and those sorts of things, but in general parameters, could you tell us, in each category, how you see the whole thing panning out?
Amanda Pritchard: As you know, the dispute is between unions and the Government in relation to pay. In terms of the next steps on negotiations, I think that is probably better picked up by Chris. I am really happy to talk about what the NHS England role is. It is obviously focused on making sure we are supporting the NHS to prepare as effectively as possible to minimise the disruption to patients, although sadly we have already seen significant disruption to patients as a result of industrial action. We are also trying to make sure we are working with unions, NHS trusts and the Government to keep patients as safe as possible through the periods of industrial action.
Sir Chris Wormald: Unsurprisingly, I have not much to say that my Ministers have not said in public, but I will set it out for you. On the Agenda for Change dispute, which is the one involving the RCN and a number of other unions, the key next steps are the ending of the ballots across the AFC groups on the deal that Government reached with the Agenda for Change. As you know, some of those ballots have come in—so the RCN rejected, and Unison accepted—but there are a number of other ballots to close, which close at the end of April. Then, the absolutely key thing is the meeting of the Agenda for Change staff council, when they decide, on the basis of their votes, their overall response to the deal on the table. The Government will then respond to whatever it is that they decide—
Q65 Chair: Can we just be clear on who is on the Agenda for Change staff council?
Sir Chris Wormald: It is basically all the non-doctor trade unions. It is quite a large number of unions. They have a mechanism whereby they come to an agreement about what the whole of the AFC staff side will respond to an offer with, which is of course not necessarily the same as what each union does. That is the next formal step, and then the Government will respond to that.
The junior doctors’ dispute is of course in a different place, and my Ministers’ position is exactly as they have set out in public: their door is open to negotiations. However, as with all our engagements with trade unions, strikes have to be paused before negotiations can begin. As you know, my Secretary of State has set out his views on the current junior doctors’ ask, which doesn’t provide the basis for a meaningful discussion. It is exactly as we have set it out in public.
Q66 Sir Geoffrey Clifton-Brown: There has been a certain amount of press speculation that ACAS might be involved. Are you able to tell us anything about that?
Sir Chris Wormald: This morning, the Academy of Medical Royal Colleges called for—I don’t think specifically for ACAS; I think they called for third party mediation, which is not the Government’s preferred route, so that is not something that we will be taking up. Of course, we agree with the colleges that the effect of strikes on patients is extremely unfortunate, so we do want to see progress in the dispute, but third party mediation is not something the Government are pursuing.
Q67 Sir Geoffrey Clifton-Brown: Again, this might be a question for you, or it might be a question for Ms Pritchard—I am not sure. Have you done any work looking at where the regulator has made recommendations to individual trusts on working conditions, particularly where those working conditions are being criticised, and the level of nurses who voted to remain on strike? In other words, there may be a link, and I wonder if you have done any work on that. It may be that working conditions are as important to nurses as the actual rate of increase in pay.
Sir Chris Wormald: I will leave Amanda to comment on the working conditions point, but on your general point on what forms our discussions with all trade unions, pay is obviously an extremely important issue. However, working conditions are, exactly as you say, also important in those disputes. Do you want to comment on the individual trusts point, Amanda?
Amanda Pritchard: I am not aware if any specific work has been done to tally trust-level results with other data, Sir Geoffrey. But what I think is absolutely clear is that it is really tough for all staff working in the NHS, and there is no doubt more that we can do to address workforce vacancies in particular—there is a huge amount of pressure on staff when they are working in a way that means they do not have the staff around them that they feel they need, but also they do not have the permanent staffing in place to be able to develop really effective, high-performing teams. That is a factor. We know the impact of the increase in demand we have seen, which has been particularly acute over this winter in urgent emergency care, but the ongoing pressures on mental health, which we are going to talk about today, and elective care all play into that. One of the things we do see as being an important component of a very complex picture here is the publication of the long-term workforce plan, which we are looking forward to, hopefully later this spring.
Q68 Sir Geoffrey Clifton-Brown: Can I suggest that your organisation looks at this? Where there are adverse CQC recommendations on workforce, I suggest you look at that and at how that compares with the percentages of nurses in those areas who actually voted to go on strike. You will see that I might have a bit of inside knowledge on this.
Amanda Pritchard: Of course. The thing we do look at—well, we look at it, but local trusts look at it in detail—is the results of the staff survey, which is an annual process that gives quite detailed feedback about what staff feel about their local experience of working. It covers everything from the support they get from local teams through to opportunities for advancement and so on. That is a hugely important piece of data. It is something that leaders pay a lot of attention to as they are thinking about all the things we have committed to in the past around the people promise, the Long Term Plan, to ensure we are focusing on retention—which is part of our job—and making sure we address non-pay related issues in a serious way. But it is recognising, as you say, that the actual dispute at the moment is specifically around pay, which is with Government.
Q69 Sir Geoffrey Clifton-Brown: Understood. I am sure the Chair is keen to move on to the main subject, but I cannot let this drop without asking you and the professor what steps—this is critical to our constituents—your organisation is taking to keep patients safe with the two actions going on at once.
Professor Powis: Throughout all the industrial action this winter, we have taken a similar approach. Our key priority is to keep our emergency pathways and critical pathways open to that—that is, accident and emergency departments, maternity services, critical care and trauma services. We have done that. In the junior doctors’ industrial action last week, we very much focused on those areas—mainly covered by consultants, but other staff as well—with a few local adjustments in terms of the services provided. By and large, those services were provided well last week, as you would expect when you put more senior decision makers into those services. The public have also played their part. We have asked throughout that the public use our services wisely during industrial action and that they do not attend A&E unless they absolutely have to, but of course at the same time urging people who have life-threatening conditions to still call 999 and come forward. That is really critical.
Some of that coverage has been fragile. There is no doubt that in some places in the country it has been a few individuals who have been keeping those services going, and they are not as resilient as they usually are. That has been a worry; but as I say, last week we managed through that. We have of course kept dialogue open with union representatives throughout periods of strike action, so if there are specific concerns in specific areas, we can have that rapid conversation around the possibility of bringing people back off the picket lines and off strike action to support services. We will continue to do that if and when there are further periods of industrial action.
Of course, all that comes at a cost. It comes at a cost to our more routine care or non-emergency care. Last week, we had to reschedule around 200,000 appointments and procedures. Clearly, that has an impact on patients. We have again prioritised more routine care, but as industrial action has gone on, we are now beginning to see the effects on, for instance, some urgent cancer care, which is having to be rescheduled. I know that is a concern not only to our local organisations, but to our clinicians, and it is something we would not want to see because those are important procedures that need to go ahead. We have asked our trusts—and they have done so—to contact people in advance so that they know if their appointments are being rescheduled, and also to reschedule appointments as quickly as possible, so that the disruption in terms of time waited is minimal. But we do know that it is having an impact on patients. There is a significant impact on some patients.
It is, of course, affecting our ability to manage the backlog. The NHS has made great progress on elective recovery. We hit our target last summer of getting below the two-year waiting time, and we are doing incredibly well. Of course, all our staff are part of this, including junior doctors and nurses, in achieving our ambition to reduce waiting times virtually below 18 months by the spring. We could have gone further, I am sure, if it was not for industrial action; but nevertheless, we are making good progress. But that is becoming harder to sustain as we go into the next ambition, which will be trying to get waiting times below the year mark, or 65 weeks.
The final impact it is having is on staff, because our staff are exhausted. They have come through an incredibly difficult three years—a pandemic to deal with. They have had the toughest winter that I think we have ever had in the NHS, with all those infectious diseases rebounding post pandemic and, of course, still covid to manage. It has been a really tough period. Of course, the strains of having to deal with the industrial action—having to cover colleagues—mean that our clinical staff, but also our operational managers and teams, who have to organise these things, are becoming really tired.
That is why we would agree that it is important that the disputes are resolved and that any possibility of getting around the table those people who are not around the table is important. Of course, there has been progress. It is important to recognise that there has been progress on Agenda for Change, though the RCN did not vote in favour of that deal, by a relatively small majority. Unison did. So it is possible to make progress, and we hope that progress will be made with the junior doctors.
Q70 Sir Geoffrey Clifton-Brown: Thank you for that comprehensive answer, professor. As you would expect, as a Gloucester MP, I have been having high-level meetings with our trusts in Gloucestershire. I think your specialist colleagues and others have heroically stepped in, including by cancelling their Easter holidays and so on. That is hugely appreciated. But even during the pandemic we did not actually have to cancel any cancer treatments in Gloucestershire, so I am concerned as to how deep this is going to go into non-elective activity in the NHS. Can you give us a little bit more information on that?
Professor Powis: We share your concerns. As I have outlined, our priority has always been, both in elective recovery in covid and in industrial action, to preserve emergency services and those procedures that are most urgent. Of course, cancer procedures—not just cancer procedures but other procedures as well—fit into that. They are urgent and need to be done within weeks or a month. Of course, local clinicians will reschedule those procedures last. They will do everything that they can with their operational colleagues to keep those procedures going.
But as I say, what we are hearing from trust executives and clinicians is that, as industrial action goes on, unfortunately some of those cases are being rescheduled. So can I guarantee that that will not occur as we go forward? No, but I can guarantee that clinicians and managers will do everything that they can to make sure that that is really a last resort in terms of rescheduling and that procedures will be rescheduled as quickly as possible. But some of these are complex procedures, and rescheduling them is not a straightforward thing.
Sir Geoffrey Clifton-Brown: There were lots of other questions, but I think we will leave it for now.
Q71 Chair: I just wanted to come in on this plan for catch-up. You have the people who were in a schedule for their treatment who have now dropped out, and you have the people behind. How are you managing that flow? Are you having people jump the queue, if you like, because they have lost their treatment? Or are people already in the process—
Professor Powis: No, we have asked that rescheduling that is a result of industrial action is prioritised. It is important that people who have been impacted directly by industrial action do not then drop back further in the queue.
Q72 Chair: Have you done any analysis of what the impact will be on people who are not affected by the industrial action, if you see what I mean, so that they are not then pushed back?
Professor Powis: Amanda might want to come in here.
Chair: It is quite a logistical challenge.
Professor Powis: It is a challenge to do that modelling, because we are not sighted on how much industrial action we are going to get and when we will get it. But 195,000 cancellations and reschedules last week clearly have an impact, and I do not think that you need to be a modeller to work out that it will have an impact on our ambition to reduce long waits.
Q73 Chair: Do you want to add anything, Ms Pritchard?
Amanda Pritchard: I think Steve has explained it really clearly. It is absolutely the case that people are working as hard as they possibly can to reschedule as quickly as possible, and I completely recognise what has been described about trying to make sure that it is a last resort to cancel those patients whose care is time-critical. There is no doubt, equally, that some of those very sizable reductions that we were seeing in the number of people waiting a long time have been affected by the action that has been taken. We can also see that the overall size of the waiting list is likely to be impacted if we continue to see action in this way.
Q74 Chair: Are you looking at offering patients the opportunity to go to hospitals outside their area if it means they can get a diagnostic assessment done quickly? You are nodding.
Amanda Pritchard: Yes, and we have had that as part of the policy we have been implementing since we launched the elective recovery plan last year.
Q75 Chair: No, but particularly around the strikes.
Amanda Pritchard: We have mechanisms that already exist to allow people to choose to go further afield if they can access care more quickly.
Q76 Chair: Are you doing any reshaping of diagnosis? I know that Moorfields Eye Hospital, which partly covers my constituency and south Islington, was using a different approach to triaging patients. Non-clinicians were doing a lot of the work so they could speed up the contact moment or assess whether a patient actually needed to be anywhere near a doctor. That seemed to work during the pandemic. Is that sort of approach being taken in other parts of the system, particularly in relation to the backlog because of the strikes?
Professor Powis: Yes, absolutely. We were doing that work prior to the pandemic. The pandemic accelerated some of that work, for instance, on virtual out-patients. Moorfields has a super virtual A&E service; you don’t actually have to attend the A&E department in person. You can go online first to see a clinician on video. That is the sort of innovation that we want to drive. We want to drive further transformation of our out-patient programmes. They have not really changed for many years, and we need to take advantage of technology to ensure that people don’t have to travel to hospitals when they don’t need to. We need to enable patients to contact their clinicians when they need to be seen, rather than constantly being scheduled in a round of appointments. That will free up out-patient time, which means we can make an impact on the backlog.
It is important to remember that when we talk about a waiting list of 7 million or so, which is actually around 6 million patients because some are waiting for more than one appointment, the vast majority of that is out-patient work. It is not in-patient or other work or day case procedures; it is out-patient work. Freeing up out-patient time and appointments through the sort of transformation that you described is going to be an important component—particularly this year—of getting from a year-and-a-half wait down towards a year.
Q77 Chair: We acknowledge that the target of a two-year wait did go. It took a while, but it has now gone. It is a sad time within the NHS when we are saying it is great that we have only 18-month waits, not two-year waits. I know you are doing everything you can, but we still have patients waiting a long time.
Professor Powis: It is, but we should not underestimate the time it takes when you have something as important as a pandemic—a once-in-a-century event—that causes a huge amount of disruption. It will take time. I have sometimes said it might take up to five years to get back. We will do it as quickly as possible, but it does take time to recover.
Q78 Chair: Finally on the strikes, there has been some conversation in the media and differing reports about the number of excess deaths that might be linked to the strike action. I wonder whether you have any firm figures on that.
Professor Powis: No, and it is important to note that many factors go into excess deaths. For instance, I think there was a colder week before that particular period of industrial action, and we know that cold periods are associated with higher death rates. Association is not causation. It is for the Office for National Statistics, the Office for Health Improvement and Disparities and others who are experts in analysing excess deaths; I would not jump to any conclusions on that.
Q79 Chair: That is very helpful, thank you. We now need to move into our main session about mental health services, which on its own could take up more than the couple of hours we have allotted. I report my thanks to the National Audit Office for its useful Report on the topic. I welcome Abdool Kara, executive director at the National Audit Office, who is here representing the Comptroller and Auditor General, and Natalie Low, who led on this work.
As I said at the beginning, we know from our caseload and from our session on Monday that this is a huge challenge. Ms Pritchard and Sir Chris, I want to get a perspective from you both at the top end. I want an honest assessment, recognising the challenges, of how you think it is going. You have had some mixed results against the targets you have set. What is your assessment of your efforts to achieve parity?
Amanda Pritchard: We really welcome the Report, and I thank colleagues in the NAO for again shining a well-informed light on such an important issue.
Mental health services remain an absolute priority for the NHS. In terms of how it is going, the story we recognise is one of some real successes, but some really big challenges still to overcome. One of the things that is called out in the Report that I think is really helpful is the way that we have moved from a situation where we had some specialised services that were very patchy to now having much more comprehensive coverage. I would point to things such as psychiatric liaison services and specialist maternity and perinatal services, as well as mental health services in schools, where we now have 35% coverage; that service did not exist pre-pandemic. I would also point to the 24-hour crisis lines, which we put in place early, partly as a result of the pandemic. There has been some really substantial progress in those areas. We have also seen a consistent increase in the number of patients who are served by mental health services, both children and young people and adults.
The thing we should also say is that while we have protected the mental health investment standard—the increase in funding as a proportion going into mental health services, and, within that, an increase in the proportion going to children and young people—we started with a really significant treatment gap. That was clearly set out in the Long Term Plan. Although all of this progress has gone some way towards increasing the level of care provided, we have seen at the same time an increase in demand, partly driven by the pandemic.
We have also seen a mixed story on workforce. There has been significant growth in the workforce that is available to support people with mental health needs, including new roles, but at the same time, there are really significant vacancies. In particular, acute in-patient areas have vacancy rates up to and around 20%-plus.
Our summary is that we recognise—and thank you to the NAO for saying this—that this has been a story of consistent and persistent implementation of the Long Term Plan, with some really significant progress. But we are in a situation, particularly with workforce, where we have a huge challenge if we are going to increase services in the way we need to if we are going to address the underlying treatment gaps and the new demand created by the pandemic.
Q80 Chair: Are you suggesting that workforce is your biggest challenge to achieving this?
Amanda Pritchard: Yes.
Q81 Chair: So it’s not the money; it is the vacancies?
Amanda Pritchard: Well, they go hand in hand.
Q82 Chair: I wouldn’t suggest that the chief executive of the NHS, sitting next the permanent secretary, would not suggest that there might be an issue with money. But if the issue is the ability to fill those vacancies, is that down to the money available in certain trusts?
Amanda Pritchard: It starts at training places and ensuring we have enough training places to bring in the new workforce that we are going to need. That is both nursing and medical workforces, but also the wider workforce associated with mental health roles. It is also about our ability to ensure that mental health is an attractive place for people to want to work and to stay once they have begun a career in that direction.
Chair: Forgive me; I jumped over Ms Blake, who we agreed would come in. Before we get too far into the session, I want to go back to Ms Blake on a particular issue that is related to this, but not directly in the Report.
Q83 Olivia Blake: I have had constituent reports and I have also spoken to royal colleges and researchers across the country about this issue. It seems that the Mental Health Act has a loophole that means the very important data collected on restraint in mental health settings is not currently being collected in medical settings where mental health patients are being held, primarily due to the lack of tier 4 beds and the fact that a lot of children are on acute medical wards rather than mental health wards. That has meant that staff who are not trained have been using restraint and not recording it. It means that security companies have been coming in to help with restraint. Sadly, it also means that restraint is being used to feed at a point when, under the guidance the patients are not actually sick enough for that intervention. Does the Department agree that the loophole should be closed in the mental health Bill that is coming forward? Does it agree that this data is absolutely necessary to protect the dignity and respect of patients with theses condition, and that we should be looking to reduce the use of restraint inappropriately in all settings?
Chair: Maybe Claire Murdoch first?
Olivia Blake: And then maybe Matthew Style?
Claire Murdoch: For sure, paediatric wards across the country can expect to see children and young people who have mental health problems, whether it be eating disorders or other problems. It is important that we make sure that staff are trained well. On the specific question of restraint, I think we need to take that issue away, because I personally think we should be recording that data. I know we have been doing a lot of work in the last two years, particularly in the last year, with acute colleagues across mental health looking at these very issues of shared care of eating disordered and other young people in paediatric settings who have comorbidities or need our joint care.
We have been working with the chief nurses to look at such practices and staff training. The Oliver McGowan training, which we are rolling out across the country, including in acute settings, is hugely pertinent here, because many of these children and young people have autism or neurodevelopmental issues as well as perhaps issues with feeding and eating and such. I guess I am saying that it is really important that we work jointly, and we have work programmes in hand right now, led by our clinical director for children’s services nationally, to make sure that our staff are fully skilled up and that there is joint care in paediatric settings where it is needed.
We have also rolled out, particularly in the last four years, specialist psychiatric liaison services in all major hospitals across the country. That means there is a 24/7 presence of trained mental health professionals in our acute settings. While some of their work is on A&E and crisis and emergency care, an awful lot of their work is on the medical and surgical wards, where again you will see both adults and children—because they don’t silo their problems neatly for us—and on general acute wards.
I would also add one further thing, which is that the NICE guidelines on eating disorders in particular would say that very often paediatric wards are the best place for children and young people who need refeeding and have physical health problems of that nature. Often one thinks that they are inappropriately there, and that may happen on occasion, but very often that is absolutely where the evidence base and clinical best practice would say they should be. That is precisely why the training, shared care and 24/7 presence of trained mental health professionals is really important. To help the Committee, I am happy to set out what we are doing in writing.
Matthew Style: Claire has in some ways made the point that I was going to make—that the statutory framework is only one part of the really important protections we have to have in place here. Claire has set out the work we have been doing with colleagues in both the mental health sector and acute trusts on this. The provision to which Ms Blake referred to in section 1 of the Mental Health Units (Use of Force) Act 2018 do have to be proportionate, but we also need to make sure that the statutory framework overall evolves to keep pace with changes in the model of care. That is why we have published a draft Bill and are currently considering pre-legislative scrutiny of the draft Bill, and I am sure we can ensure we consider the points you have raised today as part of that.
Olivia Blake: Just to follow up, it being invisible is a problem, because there are instances where a child has refused to eat once and has then had an intervention. First, that is not appropriate. Secondly, they have not had the therapeutic response needed to be able to have a feed.
Q84 Chair: I think it might be helpful to take this offline with Ms Murdoch. Apologies for breaking the flow. Coming to you, Ms Murdoch, on the issue generally of our mental health services, what worries you most about the current set-up? As I said at the beginning, we are coming at this understanding that it is a challenge, that setting parity is difficult and with knowledge of some of the issues Ms Pritchard has laid out. What are the biggest issues, and what makes you worry about delivering in this area most of all?
Claire Murdoch: Obviously I worry about the treatment gap—the 1.2 million people on the waiting list for mental health services. I am particularly focused on the workforce, as Ms Pritchard has mentioned. I am a mental health nurse and I am still registered, but that is not why I am particularly focused on it here. I am very concerned about the current shortage of mental health nurses. We are working on the long-term workforce plan, but also with colleagues—the chief nurse and others—on short-term interventions that might help us with that, because we do need more mental health nurses.
Q85 Chair: What sort of short-term intervention would help?
Claire Murdoch: We have increased the formal mental health nurse training pipeline from 3,700 a year to 5,600 mental health nurses a year. That is a material increase in the training.
Q86 Chair: How long will it take them to come through?
Claire Murdoch: It takes just over three years to train a mental health nurse, so we are doing that. Also, across the country, there has been real innovation in bringing colleagues into mental health nursing through apprenticeships, and I would ask that we ensure that the apprenticeship levy remains really easy to use, to enable such innovation. We have cadet schemes, where we are drawing young people—perhaps from colleges of further education—who perhaps do not have the academic qualifications to get into university but who can come into service and earn and learn. We train them and then they become ready, because of the skills they have, to undertake the more formal nurse training. So there are cadet routes and apprenticeship routes.
We have also recently brought in 2,000 overseas nurses as part of that pipeline, and the big thing is looking at retention as well. There is no point filling a bath with the plug out, is there? You heard some of what was said earlier about staff morale, resilience and so forth. That applies just as much to mental health. Mental health nurses tend to be older, so we are looking at that. They are able to retire at 55, so we are looking at how we enable retirement and return. I think the recent changes to the pension will help, because one hears lots about doctors and changes to the pension scheme. That affects our senior nurses and other therapists, who perhaps came into the NHS when they were 18. We do not want to lose that skill. Our senior nurses are very good at supervising, training and assisting younger colleagues coming through. Last, we are very much trying to promote mental health nursing as a really great profession. I do not regret a minute of my nearly 40 years; it has been a fantastic career.
I might just add something on workforce, since we are here. We have seen a 22% growth in the mental health workforce overall. I am really proud of the sector; I think it is one of the areas where we are possibly leading in health. We have introduced new roles in recent years to enable that growth—whether that is peer support workers and people with lived experience or, in particular, whole cohorts of people who we bring in for a year’s worth of earning as they learn. An example of that would be the mental health support teams in schools, where we have trained over 2,000 therapists to come into that programme. They quite literally attend university to do evidence-based, competency-based training for half the week, and the other half of the week—
Chair: Apologies, we will go into workforce in a bit more detail later on.
Claire Murdoch: Workforce will always be my single biggest issue.
Q87 Chair: Can I just ask where these 2,000 nurses are coming from? Which countries overseas? Are there particular countries that are providing good mental health nurses?
Claire Murdoch: May I write to you on that? I know two or three, but I am inclined to check.
Q88 Chair: Okay. It may not be significant, but I just wondered. I want to touch on the issue of talking therapies. Can we talk about waiting lists and the gaps? We get a lot of casework about people wanting talking therapies. There is a real challenge in meeting the targets for that, and there is also a rationing element, isn’t there? People sometimes want more than is possible, and there is a judgment made about how long the treatment will go on for. How are you managing that flow, and what are the particular challenges there?
Claire Murdoch: We are currently seeing about 1.2 million people in talking therapies. We know that during covid, sadly, there was a big drop-off in people coming forward, so we are also now tackling the pent-up demand as people do come forward. We have some access and waiting time standards for talking therapies—one of the few areas where we do—where there is a six-week and 18-week access and waiting time target, and we are currently hitting that at the minute. But having said all that, not as many people are coming forward as we would like. Some, in certain parts of the country, are experiencing longer waits or access problems.
We have rebranded the service from IAPT, which the man and woman on the Clapham omnibus probably wouldn’t know stands for improving access to psychological therapies. We launched it in January as the NHS talking therapies programme. We have tried to really advertise this, to encourage people to come forward. It is one of the few services where you can self-refer. We are training an additional 3,000 therapists this year. You do need a relentless training pipeline when you are growing services as quickly as we have grown the talking therapies services.
Q89 Chair: You talked about the targets. It is always great if you have a target and are meeting it, but 18 weeks is a very long wait for people who need this. We hear a lot of concerns about that from constituents. Are you content with those targets? As a mental health nurse, I am sure you would like waiting times to be shorter, but have you got an aim to reduce those wait times over time?
Claire Murdoch: We absolutely do, and I will never be content with people having to wait for services that they need; I shouldn’t be the national director for mental health in England if I were. We are absolutely looking at driving the workforce pipeline to increase access. We have advertising campaigns to try to increase the number of people coming forward—"Help Us to Help You” is the latest. We are putting the information out there, but we have to make sure that there is the service and the workforce to support that.
We do have trajectories. The Government have recently invested, as have we, in digital pathways into IAPT. We are not saying that a computer replaces a therapist, but there is strong evidence nationally and internationally that therapist-guided digital therapy—the two together—can enable us to see more patients. Before covid, patients were having on average just over six sessions each. That has gone up to eight sessions, so the people we are seeing are coming forward with more complex needs.
We are looking at a range of ways, including additional investment and additional workforce, use of digital, and advertising widely about coming forward, to try to bring those access and waiting times down. Never content, never complacent.
Q90 Chair: It does feel, as you say, like taking the plug out of the bath and then trying to fill it. There is a very big demand, which we recognise that covid has increased.
Sir Chris Wormald: You asked earlier for the Government’s view, and then we moved on, so I never got to give it. We agree on pretty much everything that you have heard from my NHS colleagues. Our view was that the NAO Report was absolutely excellent. It correctly identifies where progress has been made, and where there have been pandemic challenges and future challenges. I don’t think this is an area where there are any strategic or policy disagreements at all. Indeed, I think there is a pretty good consensus that there are the right set of measures in the Long Term Plan. Quite clearly, there was a pandemic hit, and a big demand challenge, which the NAO set out very clearly, but I don’t think there is any disagreement on what the direction of travel ought to be. It is all in—your questions have pointed to this—the sort of relentless delivery questions. On most of those, there is no silver bullet, because a lot of them are locked into the workforce questions as described.
Q91 Chair: Workforce is what keeps coming through very strongly.
Sir Chris Wormald: Yes. I think the story the NAO told is exactly right. There has been this very big increase in workforce, which the NHS ought to be congratulated on—we don’t see numbers like this across most of the NHS, as Claire said. There were some quite specific shortages in some very key professions, which Claire has pointed to.
Chair: I think figure 12 on page 46 is useful in this respect.
Sir Chris Wormald: Exactly. And then there is the colossal increase in demand. Even with this very impressive performance on workforce that the NHS has delivered, the demand is even greater than that. That is really the crux of the challenge. As I say, I thought the NAO got it spot on.
Chair: I am tempted to go into workforce, but we are coming to that a little later, so I will pause my points, but that figure on page 46 is very useful and helpful in this respect.
Q92 Olivia Blake: I have a few more questions on eating disorders. New guidance on medical emergencies in eating disorders was implemented last year. I want to read out a quick case study to show where that guidance has not been followed.
Patient A has a life-threateningly low body mass index or BMI of around 8. She cannot climb the stairs, cannot shower and cannot even flush a toilet. For the past few months, she has been cared for at home solely by her parents, having been released from prison after a lifesaving treatment. No care plan or instructions were provided to her parents. She has now been readmitted to hospital, thankfully. However, the need guidance was not properly implemented before, and she was initially discharged with no support in place. As I say, she’s back in hospital now, thankfully, but this is not an isolated incident.
Why is the guidance, a year in, still not being implemented across the board, and why is there a postcode lottery as to whether this guidance will be followed? I would like to put that question to Claire Murdoch.
Claire Murdoch: Firstly, please contact us about the individual case, and I will make sure that it is looked into thoroughly.
If only issuing guidance solved the problem! We absolutely have to support guidance with training. We work with clinical networks across the country to identify areas where we think they are underperforming or there are specific problems. You have to work really hard and focus with your clinical leads. That is our role, particularly nationally. Don’t just put the guidance out there; that is not enough. Make sure you are working with clinical networks across the country on sharing best practice between areas.
We produce most of our policies in association with the NHS Long Term Plan and new areas of service. A few years ago, we had virtually no specialist eating disorder services anywhere across the country for children and young people; we have them everywhere now. Our job is to make sure they are as productive as possible and following clinical outcomes, working with acute colleagues and others.
I think it takes more than a year—particularly a year as busy as this one, when acute colleagues and others have been as challenged as they have been—to make sure that there is adequate training and best practice, and to work with the Care Quality Commission when they are doing their inspections. We work hand in glove to make sure they look at particular hotspots, and we share information and intelligence on where those areas are.
When you are introducing new services, my experience—I am also the chief executive of an NHS trust—is that it takes at least two years of very focused clinical networks, sharing best practice, training and education, making sure you are inspecting against particular complaints or more generally as part of the inspection regime, and involving staff, patients and their families, so it is a big job of work.
Q93 Olivia Blake: Do you agree that people with a life-threatening BMI shouldn’t be let out of hospital without a care plan?
Claire Murdoch: Absolutely. We are quite clear—this would be in all areas, I suspect, of complex medicine and clinical care—that when we are discharging people, we want them to spend less time in hospital and more time at home, where they can receive intensive community support. In fact, we have increased services in the community for patients who have urgent need. When patients go home, we would expect there to be a really clear plan, and clear support for carers, on what numbers you call, how you can help this person, and so on. That is unequivocal, but that would be true for any complex-needs patient.
Q94 Olivia Blake: Given that eating disorders are the deadliest mental health disorders, does the Department have adequate oversight of bringing that number down? I know that both the CQC and the ombudsman have been critical of the number of deaths of patients from a treatable disorder; would that be a priority for the Department?
Sir Chris Wormald: I do not think there is any difference between us and the NHS on these issues. For all the reasons you give, you would find that that is a priority across Government and the NHS. But as I say, I do not think there is any disagreement between us and the NHS on the priority, and we would endorse everything that Claire just said.
Q95 Olivia Blake: Would you ever look at a prevention programme, perhaps similar to suicide prevention, around eating disorder deaths?
Sir Chris Wormald: We look at suicide prevention in the round, including the issues you have highlighted. I do not think that we have any plans for any new work on that area. Matt, do you want to comment?
Matthew Style: We work closely with Claire and her team to keep an eye on the very real risks, and to ensure that our guidance and support keep pace with changes in the way that care is provided. We will continue to do that.
Q96 Olivia Blake: Ms Murdoch, even though we have had the waiting time standards, why is it taking so long for young people with an eating disorder to get seen?
Chair: The standards are from 2015, and we are in 2023—just to put that in context.
Claire Murdoch: The eating disorder standards of one and four weeks came in later than 2015. From memory, they came into being in ’18-19, but please let me write to confirm. They are newer standards because we did not have the services. Obviously, we have to grow services in line with any clinical standards we introduce.
Before covid, our trajectory was well on track to meet the one and four-week waiting time standards. Between ’18-19 and now, we rolled out the children and young people’s eating disorder services across the country, and we were on track to meet the standards. Covid came, and as you know, we have seen a huge surge in demand for those services.
Our current performance against the standards is at 77% for urgent cases, which is the one about seeing within one week; and at 80.1% for routine cases. That is almost as high as we have ever been on the routine cases. We are now seeing an uptick in activity and the numbers of young people we are seeing. We were seeing 8,000 youngsters; we are now seeing 12,500 youngsters.
The Long Term Plan was a plan of 10 years with a five-year funding envelope. It recognises the huge treatment gap, and the fact that we need workforce, training and education pipelines, so that we can grow our infrastructure and can see more people in a timely way. The trajectory is improving, and I am hopeful that by the end of the period we will be back on track.
Q97 Olivia Blake: That was going to be my question. When do you feel confident that you will meet that target?
Claire Murdoch: We hope that over this year and next, the trajectory will continue, and that we will have the workforce. We have seen the biggest growth in workforce in the children and young people space. The growth is 22% overall, but in children and young people services, we have grown the workforce by more than 40%, so it is a really huge focus.
The roll-out of mental health support teams in schools is very relevant here, because we want to lean into the earlier intervention and identification space, and identify youngsters at a very early stage who might benefit from different interventions from the teams in schools. We have several carts moving all at once. We hope to turn off demand for the more specialist services and to intervene earlier, and to have an improving trajectory.
Sir Chris Wormald: I think this is right, but Claire will correct me if not: in the areas that you are raising, the evidence shows that poor interventions, or those done by people who are badly trained, are particularly bad and damaging. On all the points that Claire makes about training, developing and staff, there are no shortcuts. It is one of those areas where the capacity to do harm is quite high if we do not get the intervention correct.
Claire Murdoch: That is absolutely right. I would love it if we could achieve that 100% across the country tomorrow, but we need the workforce, the training and to be able to respond to the new demand that covid seemed to trigger.
We are talking to other developed countries, to see what their patterns and trends in demand have been. They have seen very similar patterns. We are hoping that some of the demand might settle as youngsters get their lives back—as they are back to school, and to the routines and supports that can help. Again, we could then identify problems much earlier, which would mean that they could be dealt with differently. We do not want to pathologise all our children and young people, but we are keeping a very close eye on those specialist services.
Chair: Figure 12 gives some very good results, as you have highlighted, for that cohort. We will come on to that when we get to the workforce. Thank you for now, Ms Blake.
Q98 Anne Marie Morris: Mr Style, I pose this question to you with your policy hat on. It is interesting to look at the areas of mental health that have been selected as the measures; there are fewer measures for mental health than for physical health, and some key areas have been picked out. We have psychosis, the talking therapies, children and young people’s services, including eating disorders, and perinatal services, and the type of milestone being chosen ranges from access to quality and waiting times. Interestingly, only one looks at outcomes, and that is the talking therapies. I am curious: why were these specific services picked? Clearly, there would have been others that would have been candidates.
Chair: For anyone following, we are on page 21, figure 4, which is what you are referring to.
Anne Marie Morris: Yes, page 21. You are absolutely right, Chair; thank you.
Matthew Style: In part, this reflects one of the factors that Amanda pointed to at the start of the hearing, which is that when we developed the Long Term Plan, we were starting from a very different place when it came to mental health services. There has been historic under-investment, and there is a huge treatment gap. It was therefore right to have a set of objectives that, on balance, as you suggest, were targeted more at expanding capacity, developing the workforce and growing access. That said, the approach, and the selection and prioritisation of the objectives, was informed by extensive and rigorous engagement with stakeholders—both patient groups and clinical expertise—through the Long Term Plan process.
You pointed to the real focus on children and young people’s services in the standards we have set; the changes in the prevalence survey suggest that that was probably the right thing to do. I think that the set of objectives is absolutely right, given the needs we see in the patient population, what the clinical community tells us is most important, and the stage of development that mental health services are at. Clearly, we would want that to change over time, and to be increasingly focused on outcomes.
As you say, we look really closely at outcomes, even if they are not up there in the headline standards. In talking therapies, we have a specific objective around the recovery rate from talking therapy services, and we have managed to maintain progress on that outcomes measure. Even though, as Claire said, patients have been presenting with more complex needs, we have managed to maintain that recovery rate.
Q99 Anne Marie Morris: I am intrigued. How are recovery rates measured? My experience as a constituency MP is that individuals get given a package of five sessions or whatever, and that is it.
Chair: You are talking about talking therapies in particular.
Anne Marie Morris: Talking therapies, yes. Are you measuring whether the person has resolved their issue, or are you simply measuring whether they have their five sessions?
Matthew Style: In the talking therapies programme, there is patient-level monitoring of outcomes, not just course completion rates. The care provided is more individually tailored than a standard block. As Claire said, the number of sessions that people have been offered has grown over the pandemic in response to changing patient need, as opposed to there being a standard model.
Q100 Anne Marie Morris: Ms Pritchard, what criteria were used to decide on the areas—psychosis, talking therapies, etc—where targets would be set? I understand that there were a lot of conversations with stakeholders, but there must have been criteria used. You must have concluded that those were the areas that needed to be covered. What got left out that might otherwise have been left in? Dementia isn’t here.
Ms Murdoch helpfully talked about the support in schools. Special educational needs crosses two Departments, and one of my concerns—I see this in my constituency—is that the health element is often missing. That is why we have such a challenge in Devon. On the criteria, what was excluded and why?
Amanda Pritchard: The identification of these particular standards goes back to the Long Term Plan from 2019, which was before my time, so it might be more helpful to ask Claire to comment on that. We might pick up the more recent clinical review of standards work, which Professor Powis led. That has concluded. You will have read in the Report that we now have new standards to introduce, which pick up particularly on waiting times around urgent care and community care. Those are the next big milestones to add to the basket of measures that are used to give an overview of where we are with mental health services. I don’t know if that would be helpful.
Chair: Ms Murdoch, briefly.
Claire Murdoch: Very briefly, selecting areas has been a big task of prioritisation. There are lots of choices about what goes first, what we don’t do yet, and what we will move on to over the 10 years. There has been very wide engagement over a long period of time with leading clinicians, campaign groups, people with lived experience and people in the field, to try to think about where we can make the biggest difference first. We introduced the one and four-week waiting times for children and young people because we thought that the need was desperate, and that we could change the demand curve and the outcomes. We worked with many people to decide how to prioritise in an area where so much needs to be done. We are playing catch-up over decades, so there are choices.
On clinical standards and access waiting times, we agree strongly that, now that we have put services in place and they have been embedded, we need to move to outcome measurement. We have a big programme of work in place this year—right now—in which we expect all services to move towards paired outcome measurement, which will include patient-reported outcomes. We are working with leading experts to make sure we have the data and technical capability to record them easily without creating a bureaucratic nightmare for staff. They must also be meaningful outcomes. That work is in play now, and by the end of this year we hope to be in a position where at least 50% of patients have reported paired outcome measurements. The clinical review of standards work is equally really important.
Professor Powis: Yes, that also came out of the Long Term Plan work. The Prime Minister at the time asked us to review standards from a clinical perspective across a range of areas—urgent and emergency care, cancer, elective care and mental health. The key bit there was that we did not have a broad range of waiting-time standards in mental health in the same way that we have in physical health, so for me it was extremely important that we established those as part of the parity of esteem question. We have done that. This is irrespective of the particular condition; it is a broader range.
For very urgent presentations, patients should be seen within four hours of referral in a community response. Those in A&E should be seen within an hour. For urgent presentations, it is within 24 hours in the community, and for non-urgent referrals in the community it is a four-week waiting time. We consulted on that last year, and 81% of respondents were in favour. The Government welcomed the standards in the response to the consultation, and we are in the process of putting in place those standards. We will be looking to start publishing how we are performing in the months to come.
Chair: Thank you very much. Back to Ms Olivia Blake MP.
Q101 Olivia Blake: I have a quick question following up on the community mental health and A&E-based targets. When do you envisage that they will be reduced, and why has there been such a delay?
Amanda Pritchard: Shall I start? I am sure that Claire will want to come in. We are expecting to start publishing the data against the urgent and emergency care times this summer, and then on community by the end of the year. Some of that does reflect the huge amount of work that has gone into improved data collection and introducing new data collection over the last few years. I think we have gone from something like 100 different measures that were previously recorded to now having over 400 different measures that are routinely recorded and reported.
Equally, in terms of numbers of providers who are submitting data, back in 2016 I think there were about 90 and now there are over 350-ish. The team has done a huge amount to try to introduce both mechanisms for data capture and to encourage compliance and people to report that data. In addition to publishing data, the next really important step is also to agree with Government what the standards are that we will be setting around trajectories for working towards meeting those standards. Exactly as Claire was saying earlier, some of that clearly depends on having the services and the workforce available, but what is really helpful is that we have now got a widely agreed, consulted on, Government-supported set of ambitions that do pick up some of the gaps that were previously acknowledged in the data.
Q102 Mrs Drummond: In the Report and the pre-panel, data was brought up. Data is being collected, but it was not known where it was going or whether it was being used effectively, so I am really pleased to hear that you are starting to use that data. Will it be used for commissioning, too? I think that 16 out of 28 ICBs have not got enough data to commission mental health services. Is that a focus at the moment?
Claire Murdoch: Absolutely. As Ms Pritchard has said, we have made huge progress—it was slowed down by covid because we diverted some of our attention, but we have really ramped that up now—and it is essential that commissioning is informed by access and waiting times measurements and outcome measurements. Who wants to keep commissioning a provider who is not delivering good outcomes or does not know where the worst waiting lists are?
One of the complexities for us in mental health, which not all areas of health face, is that we are hugely committed to working with third-sector organisations in our pathways, and it is really important that we do. We have had to work with those partners as well on being able to set up the measurement and collect the data. That has been slightly more technically difficult, because some of those providers have lesser infrastructure and so on, but it is really important that it informs commissioning decisions.
Q103 Mrs Drummond: Shared data was a big issue, too. Are you putting measurements into place so that you can share data across the organisation and with the third sector as well? That is crucial across the health service, but particularly in mental health.
Claire Murdoch: Of course, we hope that integrated care systems across the country will make huge progress around the sharing of data, looking at people living with complex conditions and understanding how this information flows into their commissioning and support for people. So, yes, the data sharing is a very big priority. It is not always easy. I am sure you will have heard in this Committee before about interoperability and other such things. But there is a huge commitment to that, and the ICSs especially will want to use data in that way.
Matthew Style: In addition to ensuring that the increased data is made available for commissioning, it is also really important that, as the quality of that data improves, we make it available publicly so that there is increased transparency around access to mental health services and performance and quality issues in mental health. It is really important to the overall parity of esteem agenda that mental and physical health services have the same degree of scrutiny and transparency.
Q104 Olivia Blake: To go back to a data point, we heard on Monday about GP referrals getting refused, and the NAO Report picked up that that does not seem to be counted anywhere. In my view, you do not see what you do not count. What do you feel about that? Is that masking the success of access for patients?
Claire Murdoch: I think that I will need to write to you about what we do collect, in terms of a straightforward answer to that. However, to add to that, the community transformation part of our Long Term Plan is where approximately £900 million of the £2.3 billion is going. We do mean transformation: we don’t just mean more; we mean different. Some of the key elements of that transformation programme are care wrapped around primary care, so that they stop referring back and forth and we stop the ping-pong, and we work with PCNs and local neighbourhoods in quite different models of care. That’s one element.
Local authorities are important as well. I saw your witnesses on Monday talking about the need to understand data and outcomes in the round and to the fullest extent—housing, social care and social prescribing. ICSs in particular, and the work that they do at place, will we hope work in ways with the community transformation programme to have a different model of care, particularly if somebody has a long-term mental health problem and they are going to need different levels of support for a long time. It is non-value-adding transactional time to just keep referring them between community service and primary care. That is a core part of the transformation that we are trying to drive and put that money into.
On the question of what exactly we collect by way of data on referrals—maybe mental health services signpost GPs to other resources, meaning they do not take them into specialist care—I will need to go away and look at what we do collect.
Q105 Sir Geoffrey Clifton-Brown: Ms Pritchard, can I press you on the issue of data and ICBs? Paragraph 12 on page 8 of the Report states: “In our survey of ICBs, only two of 29 said they had all or most of the data needed to assess variations in patients’ access, experiences and outcomes.” ICBs are an ideal opportunity to bring different parts of the whole system together—different departments, local authorities, social services. If the data is not being co-ordinated properly between them, we are losing a lot of the benefit. What work is your organisation doing to improve the gap?
Amanda Pritchard: I am at risk of repeating some of what Claire has already said, so let me not do that, but I absolutely recognise that ICBs are still relatively new. What they are doing is building on a lot of the strength that previously existed in CCGs. They are trying to do that much more complex and valuable thing, which is to join up the data and intelligence across not just health services but also, as we have said, the voluntary sector and local government, too. They are trying to make sure that they make the right connections between what is happening at a local place level and at the wider ICB level.
Some of that is more straightforward than other things, partly where data sharing is in place, so that is why the data sharing is such an important part of this agenda. We can see those parts of the country that have really invested the time, energy and effort in this. One of the things that Claire is trying and that we are trying to do is to share best practice and promote some of the great work that is happening in parts of the country so that everyone can benefit from that.
I was up in West Yorkshire a couple of weeks ago. They have third-sector representation at their ICB really embedded well, they have place structures that work really well, and they have prioritised mental health and mental health data in a way that has given a real blueprint for how others might wish to do it themselves.
Q106 Sir Geoffrey Clifton-Brown: It is the old story, isn’t it? How do you ensure that the worst actually adopt some of that best practice that you have just been talking about?
Amanda Pritchard: That is exactly where the strength of the national mental health programme has really shown itself in the last few years. It is exactly what Claire and her colleagues have been doing. We have things that I have mentioned before, such as the perinatal specialist services or mental health teams in schools. They are not just in those places that have been really proactive and advanced in their thinking. They are models that are then shared more widely.
The work that Claire and her colleagues do—I’m sorry that I am speaking for her on this—is very much with our regional teams and also with ICBs. There is quite a level of detail to make sure that they support those parts of the country to implement services in line with the Long Term Plan and the mental health investment standard. Partly, it is also about getting those clinical leads working as a network, working as a learning collaborative across the country, and building on and learning from those places that have done things well.
Q107 Sir Geoffrey Clifton-Brown: As you are probably aware, the Committee visited Denmark to look at the whole health service and to look particularly at how advanced it was digitally. Have you been looking internationally at what is happening elsewhere and at some of the best exemplars around the world?
Claire Murdoch: Can I clarify the question? Looking at exemplars on data or—
Sir Geoffrey Clifton-Brown: Data, yes—at how well they are using data to integrate the various bits.
Chair: The Danes are particularly far ahead on this and have been for decades.
Sir Geoffrey Clifton-Brown: It is about how to integrate different bits of the health service and elsewhere.
Claire Murdoch: Without taking us down a rabbit hole, it is one of the big things that is behind the federated data platform, which is currently in a procurement process at the moment. That is absolutely about recognising that we have lots of different systems that collect data, but that the need to have something that brings all that together in a way that can then be used for multiple purposes, including the planning and monitoring of health services, is a critical gap that we need to close. That is really what that is about.
Q108 Chair: Professor Powis, can you give a sense of how this will affect things clinically?
Professor Powis: I am absolutely with you on this. Clearly, the use of appropriate data and the sharing of data are absolutely critical to any modern healthcare service, and that is absolutely what we are doing. There is a huge degree of complexity beneath that, of course—just ensuring that there are systems in place that can collect the together and ensuring that they talk together. The federated data platform is a way of bringing datasets together. We saw how that was used during covid to great advantage, and we want to continue that. Then, all that data can and should be used by local systems to drive improvement.
Q109 Chair: When will that be up and running?
Professor Powis: Because it will always evolve, you will always be moving along this pathway—we see advances in data all the time. But the first task, of course, is that in primary care we have data systems in place, and that is a question of sharing. In our acute trusts, we have electronic patient records to collect data in most trusts but not all. I think we are lagged a bit in some of our mental health services, unfortunately, and we need to get that up to speed as well. Claire, you might want to say a little bit more about it.
Q110 Chair: Just briefly, on the timeframe, when will we see a difference?
Claire Murdoch: I think there has been a lag, and we need to make sure that investment in the digital capital is on a par with other services. I know that it will always be constrained. I am loth to say it, but one of the benefits of covid was, in mental health, a huge transition to seeing more patients digitally and staff becoming more digitally competent. Obviously, we are now doing work on all these different platforms.
This year alone, we are doing a further refinement of the mental health minimum dataset, to try to consolidate sources for information on mental health. I think we are on version 7 of 8 now, so that continues to happen. We are rolling out the clinical review of standards and measurement of waiting time. We are rolling out the measurement of outcomes, so they will be there.
In fact, the other big thing we are rolling out is a new currency and a new way of understanding activity, outcomes and payment. We are working with pilot sites over the summer, and by the end of this year—ready for 1 April next—we hope to be in a position to roll that out as well. That is going to be critical, because as part of that we will want patient-level information on costing and all those things. So I am hoping that we will play rapid catch-up.
Q111 Chair: Mr Style, do you have anything to add briefly?
Matthew Style: I did want to add something, because I think it is one of the most decisive steps that we have taken—precisely to Sir Geoffrey’s point as to how we encourage everybody to do as well as the very best trusts in terms of the data and information they collect and report. It is that—the NAO makes this point—after decades of mental health services being characterised by the use of block contracts, we have taken a very decisive step to shift towards more activity-based payment in mental health. I think that that is one of the most powerful tools we have in our toolbox in terms of improving the data that we collect, both about activity but also, crucially—this is the Public Accounts Committee, after all—about the cost of services and value for money. I think that that is a critical enabler and a decisive step that we have taken, and we must make sure that we get the benefits of that.
Q112 Sir Geoffrey Clifton-Brown: Ms Pritchard, I did not quite get the answer about whether you are looking at international comparators. The Committee learned a lot from its visit to Denmark. If you have not already sent your people there, can I tactfully suggest that you might consider sending your people there? No country has a monopoly on the best ideas. It seemed to us that they are very well advanced in this field.
Amanda Pritchard: We completely agree, and it is, again, something that we have done. In all areas, we try to make sure that we are looking—
Q113 Sir Geoffrey Clifton-Brown: Particularly with the inception of ICBs.
Amanda Pritchard: Exactly—looking internationally and learning is also—
Q114 Chair: The pandemic has also sped things up. We can now get things on our phones that we did not even know existed before.
Just briefly on this thing about data sharing, are there any legal barriers, Sir Chris or Mr Style, that the Government need to change in order for this level of information to be shared?
Sir Chris Wormald: No. As you know, it is more about how you do it. I do not think there are any different legal challenges to any other area.
Q115 Chair: It can often be used as a reason not to share. Organisations get very nervous about sharing data, because they worry that they are breaking the law. It is very useful to hear that, categorically, from your point of view, there is no problem there.
Sir Chris Wormald: Yes. I am not aware of them, and I should say—Claire will be far too humble to say this—that this was an area that the NAO picked out. Mental health has been particularly good at sharing good practice and tackling the variability issues that Sir Geoffrey was pointing out. It is in paragraph 1.10 on page 22.
Chair: That is also partly because of the starting base, I guess. That meant that you had a chance to improve rapidly, where you have improved, across the piece.
Claire Murdoch: On that point about the sharing of best practice, I want to commend our partners because, in the Long Term Plan, we do have this whole governance structure of the programme board, where royal colleges, third-sector organisations and others sit with Department of Health colleagues and really help us think about whether we are getting the reach and where we have issues.
Chair: In your previous answers, that has come through very clearly.
Claire Murdoch: Has it? Very good.
Chair: I think we have got that message. Thank you very much.
Q116 Olivia Blake: Do we know why the gap in life expectancy between people with severe mental health needs and the rest of the population has widened? That is to Ms Pritchard.
Chair: Or if you don’t think that is you, pass it on.
Amanda Pritchard: I was expecting it to go in a slightly different direction, but that is fine. Claire, it might be that you want to pick that up from a specific perspective, and then I am happy to talk about the general principles.
Chair: There were really hard-hitting facts in the Report that we were worried about.
Claire Murdoch: Essentially, we know that there is an unacceptable premature mortality gap for people with mental illness. One thing that we certainly very much welcome—we welcome everything in the National Audit Office Report—is the recommendation that we are clear about what parity of esteem means. That is not just—although, importantly, it is—coverage of decent mental health services across the country in 10 years there; it is also about really good access to physical healthcare.
We know that the premature mortality gap has increased slightly in recent years. We suspect, but do not know, that some of that is an effect of deaths from covid because 50% of people with serious mental illness will die with respiratory-related disorders. There is a high prevalence of smoking among the group, and we have been pushing, as you will know, for physical health checks for people. We have achieved more in the last year than ever before: more than 256,000 people are having regular, annual physical health checks. We have been trying to incentivise those, quite often through payments to GPs, through working with the third sector, through training, through measurement and through making it really clear that we expect these annual health checks to happen.
However, the checks are just the start; you need to act on them and formulate plans. Why has there been an uptick in those deaths? We do not yet fully know. We have to work, and are working, with OHID and others on that. Professor Powis may want to say more. We put a big focus on that during the pandemic, when we diverted some of our planning and work to making sure people with serious mental illness got the flu vaccination and the covid vaccination. That was a huge and very significant focus.
Q117 Chair: You are very alert to the issue, but you don’t know why the data—
Claire Murdoch: We are alert to it, but we do not know for sure, unless Professor Powis wants to add more.
Professor Powis: All I would say is that, clearly, we recognise the issue. We have talked about measuring outcomes, and I would have thought that this is one of the key outcomes that absolutely has to improve.
Q118 Chair: I have to say that I commend the work of the Greenhouse practice in Hackney, which works with homeless and vulnerable people and has a very good combined service. It has actually won an NHS parliamentary award for its work, but the difference is that the clients there feel that they are getting holistic primary care, compared with going to a regular GP, who I know do excellent work, but perhaps do not see the whole thing.
Sir Chris Wormald: Yes, that is very important, and it goes with the point Sir Geoffrey was making about integration and ICSs. One of the absolute key facts—it goes with Claire’s point—is that something like a third of people with long-term mental health conditions also have a long-term physical health condition, and the interaction of those two, of the type Claire described—
Chair: In a busy GP practice.
Sir Chris Wormald: Yes. That is where the GP bit is particularly crucial, and then the ICS bit, including all the data sharing between those types of conditions.
Amanda Pritchard: My apologies, I thought the question you were going to ask was what we were doing about it—that is what I was ready to answer—which my colleagues have partly picked up.
Do you mind if I just also call out the importance of the Core20PLUS5 programme? It is one of our flagship programmes, and focuses particularly on tackling inequalities. This is obviously a hugely important part of the inequalities agenda from multiple different perspectives. The programme particularly focuses on five things, and physical health for people with serious mental illness is one of them. It was launched, coincidentally, just before the pandemic, but it has been particularly important, and is becoming more and more so, as it becomes more obvious what some of the longer-term impacts of the pandemic have been.
Chair: We are moving on now to what is happening with community-based services.
Q119 Mrs Drummond: I want to talk about the ICBs. Are they going to be putting mental health as a priority? I know they are all going to be different, but how are you asking them to put that into place?
Amanda Pritchard: Mental health absolutely remains one of the top priorities for the NHS but, as Claire says, it is the NHS in partnership. It is very clear, I think, that it is something our partners in the voluntary sector and local government feel equally strongly about, and we are working very closely in a very joined-up way on that.
There are two things it is probably worth saying. We have massively reduced the number of things we are asking of the NHS through our operational planning guidance. I will give you an example of why I can say so confidently that we haven’t in any way stepped back the priority on mental health: six of the targets relate to mental health, while another two relate to learning disabilities. Overall, a quarter of the total number of things we have asked of the NHS this year relate to mental health and learning disabilities—I should also say that services for autistic people are covered within that. That sends a very clear signal about how important we continue to see it as.
The second thing, which is also a really important safeguard here, is around the mental health investment standard, so ensuring that that funding continues to be earmarked for and spent on services for people with mental health conditions. As we said before, even within that, a greater weighting towards children and young people continues to be another really important safeguard, so that that priority is supported with the resource to then deliver on the ground.
Matthew Style: If I may just add, there is, of course, also a duty arising from the Health and Care Act on the chair of the integrated care board to ensure that at least one member of the integrated care board has experience in the prevention, diagnosis and treatment of mental health. It is particularly singled out, in a statutory sense, as a priority in terms of the focus of the board itself.
Mrs Drummond: I was at a business forum and one employer said, “What are the Government doing about the mental health of my employees?” I just wondered whether there was any training that you could give employers—
Sir Chris Wormald: There’s quite an obvious answer to that question.
Q120 Mrs Drummond: I don’t think it is the Government’s job to tell employers how to treat their employees. Do you have comments on how employers can access information so they can help with mental health in their workplaces?
Sir Chris Wormald: As I say, the first part of the answer is very obvious: all employers should take this extremely seriously as part of one of the things that they do for their staff. In some ways, that is the most important step of all. We do a whole range of things—I think Mr Style is probably best placed to comment.
Matthew Style: As Chris said, it is always an important part of the agenda in terms of how we can support employers of all sizes to ensure that they are taking their responsibilities to their employees seriously. I think it is particularly important in the current economic context, where the Government recently announced a series of measures focusing on keeping people in the labour market and bringing them back into work. It is particularly important that as part of that programme we are working with employers, both to support them in developing their own services but also to ensure that statutory services—both those provided by the NHS and those provided in Jobcentre Plus—have really close relationships with local employers and so on. That is more important than ever in the current economic context.
Q121 Mrs Drummond: Across services like the police, local government and so on, do you think the ICBs are the best place to help with that and integrate that? Obviously, the police have to pick up a lot of mental health issues; the people they arrest often have mental health issues.
Sir Chris Wormald: Basically, yes. This is the type of problem that ICBs were invented to solve. We continue to have, as you would expect, a national dialogue, both with local government and with other statutory services, about the national picture. But as your questions throughout the hearing have been pointing to, an awful lot of the solutions are in local places and about how the local services interrelate. As I say, that was the exam question that caused ICBs’ creation, as it were.
Q122 Mrs Drummond: It is of course a lot of pressure on them to have to solve all the issues that—
Sir Chris Wormald: Yes. But I think the discussions at this hearing have played this out: there are some vitally important national interventions that clearly make a difference, in terms of individual services and the setting of the frameworks, the data and all the things that the Committee has raised; and then there is a set of things that can only be settled locally. So it is high pressure, but there is no other way round it, because some of the types of issue that you have been raising are ones that nobody sitting in an HQ building is going to solve; they are going to be solved between two professionals, working in a place, who understand the community and so on. You’re completely right: it is very high pressure. But I don’t think there is another flavour of answer that gets the kind of local nuance that you have all been pointing to.
Matthew Style: At hyper-local level, the funding that we have made available through what is called the additional roles reimbursement scheme nationally allows GP practices to employ people in patient-facing roles, including mental health practitioners, and the purpose of those roles is almost to ensure that there is more capacity in a GP practice and across a primary care network to do that much more integrated engagement with other service providers locally, to look at the broader biopsychosocial needs of the patient and to reach out to other agencies as well. As I say, there is dedicated national funding through the additional roles scheme for those professionals in GP surgeries.
Q123 Olivia Blake: I want to ask about the support and monitoring of community-based services and how you feel that is going or can be improved.
Claire Murdoch: Sorry, by “the monitoring of community-based services”, do you mean the roll-out of the priority community services that we have mentioned in the Long Term Plan and how we monitor those?
Olivia Blake: Yes. Sorry I wasn’t clear.
Claire Murdoch: I just wanted to double-check before I trotted off in the wrong direction.
We collect the data—we talked earlier about the mental health minimum dataset, where we have gone from 100 points of collection to 400 points. We are trying to build into that growth the Long Term Plan deliverables and how they are taking off. We talked earlier about IAPT. We also know that more than 73% of services across the country have moved to our transformed model of community care, as specified in the Long Term Plan. We know that more than 50% of GPs, for example, as part of that will have the new ARRS roles working with them; it was 57% last time I looked. We are really keen to roll those out, because we think they are a big support—huge support—to primary care. They bridge-build between primary and secondary care. Again, they are vital in that—stopping the flipping back and forth of referrals. We can measure all sorts of things: what progress is being made around eating disorders, psychosis or the term “personality disorders”. Within that community transformation—it is £900 million of the £2.3 billion, so there are lots of different patient groups within it—we are able to do a great deal of measurement.
What is also really good at the minute is that ICSs in local areas are able to say, “We think we’re lagging behind. Can you help us?” I like to think that instead of this great hierarchy, there is one mental health team across the country in a way, because we are all committed to this. So there is also free dialogue, where local areas will ask for help and support—will ask us to point them to wherever is doing better. We have a whole governance structure, which the National Audit Office Report referenced, that is pretty well developed and we are very committed to publishing data and information on progress.
Q124 Olivia Blake: Is there anything that you would like to see in terms of support that does not currently exist? In an ideal world, if you could wave magic wand, is there any improvement that you would like to see in being able to support community services?
Claire Murdoch: In some of the areas in the Long Term Plan—the clinical areas, and the transformation and the growth that we have talked about—we know that, by the end of the Long Term Plan, if we hit all our trajectories and deliver on our promises, there will still be a big treatment gap. In areas such as eating disorders or children and young people—the mental health support teams in schools—why would we stop at 35% of the country covered when, at the minute, there is international interest in what we are doing? We want to work over the next five years of the Long Term Plan to have arrangements in place for funding the workforce and everything else to close that gap, cover all our schools, and try to fundamentally change the face of early intervention and mental health at a young age.
I could go on. I definitely think that we need the right amount of capital in the right place to make sure that we can localise services and bring an end to out-of-area placements. I think I have to stop here: workforce, capital and closing the treatment gap, and then, within the NHS, with what we have right now—we have talked a lot about it—to keep driving standards and quality, also optimising efficiency and productivity and seeing as many patients as we possibly can. I would love not to have a 1.2 million waiting list.
Olivia Blake: Capital came up on Monday.
Chair: Figure 15 is useful in this respect, on page 54.
Q125 Olivia Blake: Yes. Lots of people are obviously fighting over NHS capital. There is clearly a therapeutic benefit to having that thought through. We saw that again on our Denmark trip. I am just wondering what the plans are for capital going forward, beyond this plan.
Chair: The figures in figure 15 are quite stark. I would highlight the column for 2017-18. The total capital expenditure as a percentage of backlog maintenance was 107%. Last year it was 25%.
Olivia Blake: And I think they said on Monday that 2% of the new hospitals scheme is allocated to mental health.
Matthew Style: The first thing I would say on that is that one of the recent changes that we have made to the way that capital expenditure is allocated across the NHS is in large part to put those allocative decisions in the hands of local NHS leaders. ICBs are, in my view, the right people to prioritise between the capital needs of the local NHS. In particular, the funding for backlog maintenance sits in the hands of ICBs in the main, and we do not dictate nationally the proportions of that that should be for mental health or physical health services, or indeed for primary care or secondary care. I think that those judgments are best made by local leaders.
Q126 Chair: It is all very well making the judgments, but if you look at figure 15, the total capital investment required to eradicate backlog maintenance was £855 million and the total capital expenditure was £219 million in 2021-22. There is a gap, isn’t there?
Matthew Style: The needs are clearly very significant.
Q127 Chair: It is all very well making a decision locally, but if you do not have the money to do it—
Matthew Style: On top of that we have provided targeted investment nationally. In particular, we are investing over £400 million in eradicating dormitory accommodation across the NHS, which is clearly something that should have been done many years previously. There is targeted investment, as well as the scope for leaders locally to prioritise.
Q128 Chair: Ms Murdoch, earlier you touched briefly on mental health teams in schools. I wondered how well that is going. We will talk a bit more about the workforce, but are those stable groups? Are you hoping that there will be some stability in those teams in schools, and will the NHS be committed to continuing to fund this? I will go to Ms Pritchard on that, and Ms Murdoch.
Claire Murdoch: Let us start with the last point first. We have the funding within the Long Term Plan for the first five years agreed and identified. Obviously, we have to agree with Government the next five years and the investment standard and parity, and where the Government want mental health support teams in schools to go. I have made it clear where we would like them to go.
Secondly, I am really proud of this whole programme because we came from a standing start. It is evidence based. It started in covid, when all the schools were shut. We immediately had to pivot to work with schools on outreach to the youngsters and families they were most concerned about. A short while ago I visited a boys comprehensive school in south London, and it was amazing just how much the Department for Education, the Department of Health and Social Care and NHS England had worked with the school to make sure it was embedding the work of the mental support team in the school with their whole-school approach. The headmaster took me proudly around his school to meet the boys, explaining that they could all cook 29 healthy meals by the end of key stage 3, they would run a mile a day and they would do mindfulness and so on. The mental health support team in the school was augmenting this whole approach.
Q129 Chair: You are saying that these teams are not just dealing with the acute end of it?
Claire Murdoch: They are in schools dealing with mild to moderate mental health problems early. They work with the school mental health lead. There are three components to the programme. First, all schools should have an identified, trained mental health lead. Secondly, all schools should be covered within the envelope we have by a specialist team that we have trained to deal with common mental health problems. Thirdly, there should be a clear and active bridge to CAMHS and specialist services that supervise the teams in schools. That is the whole package. The schools that are doing it best are embedding it as part of a whole-school approach to mentally healthy, emotionally well-adjusted and physically fit children. The programme is going really well.
Q130 Chair: Do you have any understanding of how many are doing the best? How many are doing that holistic whole-school approach?
Claire Murdoch: That is something we are having evaluated at the minute.
Q131 Chair: That was my next question.
Claire Murdoch: We are working with UCL and others to do a proper evaluation of how this is going. By any measure this is a very new, nascent programme. We see lots of examples of schools that have really engaged with this.
Q132 Chair: Professor Powis, you are in charge overall as medical director of all these interventions. Are you asking the evaluators to look at what cost savings there are? Logic would suggest that if you intervene earlier and catch young people and give them the resilience they need to cope later in life, it will lead to a healthier population. Is that part of your evaluation?
Professor Powis: Claire can answer that specific question, and the answer is yes. That has been a golden thread through everything you have heard from Claire. As with many physical conditions as well, early intervention and prevention is obviously better than treatment and care. It is one component, but it is not the only component of trying to get to earlier stages and to prevent mental health from deteriorating and mental health problems from occurring. Clearly, prevention is better.
Q133 Chair: They will need to prove that for the bidding round in about four years’ time.
Claire Murdoch: It is part of the evaluation.
Q134 Chair: We are nearly one and a half years into the programme.
Claire Murdoch: Three years from the very first ones, which started in the middle of covid.
Q135 Chair: Just to be clear, when does this funding envelope run out?
Claire Murdoch: This year is when the funding finishes. But from within the NHS envelope we have found some money for a further year, but between us all, because this relies so much on the trained therapists and the workforce pipeline we talked about, we do need to be really clear what is happening the year after next and the year after that.
Q136 Chair: Evaluation will come to nothing if it comes to an end. Have you got that in mind?
Claire Murdoch: Indeed.
Q137 Chair: At the moment is the addition coming out of your central budget, Ms Pritchard?
Amanda Pritchard: It is all part of the current spending review settlement. Claire is rightly saying is that there will clearly come a point when we are having a conversation about the next spending review settlement. At the moment, I have to say that I would be extremely surprised if there was not an enthusiasm to continue with this programme, but that is where the evaluation will be really helpful to show us that it is delivering the sorts of benefits we anecdotally are hearing about. But we would also say that it is important that we look at things in the round, with all the other aspects of mental health funding, including Claire’s point about workforce.
Chair: We are coming to workforce in a moment, but before we do I want to turn to Ms Blake.
Q138 Olivia Blake: I just want to ask a quick question about SEND and how this integrates, and how we can make sure it is as accessible as possible to all young people with SEND needs.
Claire Murdoch: The expectation absolutely is that it is in our guidance, and we are revisiting it as a result of early evaluation. Young people with autism or learning disabilities still have mental health—
Olivia Blake: Or hearing loss.
Claire Murdoch: Yes. Work definitely has been done on the basic training, the operating manuals and the support we are giving to mental health support teams in schools locally to ensure we are not excluding anybody from the support this team can give. They are not a team that provides specialist treatments. Therefore, they need to be able to refer through to the specialists. That is why it is important that specialist CAMHS services supervise, because they can then pull youngsters through who need more help. But absolutely nobody is to be excluded from care and support from these teams.
Chair: We are tempted to go down a whole SEND route because we have discussed this a lot with the Department for Education, but we will not today because there are many issues there that are beyond the reach of even the guest witnesses in front of us today.
Sarah Olney has been waiting patiently.
Q139 Sarah Olney: Can I just quickly pick up on some of those points about mental health in schools? It refers to something I was going to pick up later, so I will bring that forward. I was really interested in what you were saying about that boys’ comprehensive school, and I would love to know which one it was. I am not asking you to reveal it publicly, but it could be one that some of my constituents attend. That is why I am really keen to hear about all of this, partly because it often feels like young people’s mental health is, in my constituency, the key health issue we are experiencing.
One thing that often occurs to me, and I am speaking as a parent of a 13-year-old as well, is that there is a real lack of information for parents at all stages. First, just generally in our parenting approach, what should we be doing? What does the evidence show is a way to create a beneficial environment at home for young people? Also, once it gets to an acute stage, with the very long waits that we are experiencing in my constituency, what do parents do in the meantime? They are terrified of responding poorly. In particular, we have real problems with things like self-harm and eating disorders. When you are waiting a long time, parents just do not know how to take the best care of their child during that time. Extending what you were saying about within schools, which sounds excellent, what more can your service or the NHS do to help parents in particular, but anyone who has contact with young people outside of school, for outside of school, in wider society and that public health approach?
Claire Murdoch: The beauty of the mental health support teams in schools—if they are fully optimised and if ICSs in places really see them as not just a school thing, but a local community resource—is that they absolutely do provide and offer training for parents. The school I visited had run several sessions for parents on common mental problems and how best to respond to them. They also provide training to youngsters about common techniques for building resilience and coping with the common problems of being younger, whether that is exam stress, bullying, peer pressure and so on. They are part-assessment and treatment of those who need an evidence-based course of intervention, but they are also about building capability and capacity within not only the school, but the parent group and pupil group themselves, so they are more able to cope. So there is that.
At the moment, with the treatment gap we have in specialist children and young people’s services, and some of the people on the 1.2 million waiting list are young people, many places across the country—we have tried to support this nationally—have been looking at programmes with third-sector partners around parent support and education while you are on a waiting list. There is a phrase “waiting well”, which I don’t like, but part of what sits under that are who to call for help.
We have the 24/7 crisis lines if things really become tough, but we definitely have invested in more joint work with those third-sector organisations and others about, “Don’t just leave people on a waiting list.” You can achieve a lot, especially now we do more digitally. You can run parent groups. You can run groups for youngsters who perhaps are not yet having the specialist intervention they are waiting for, but can ask more general questions. We are trying to produce more materials for support as well.
Chair: Thank you, Ms Murdoch. I don’t want to cut you off—Ms Olney.
Q140 Sarah Olney: Workforce has obviously come up time and again, both in the session and for all of us as constituency MPs—it is what we hear. Sir Chris, obviously there has been a lot of chat about a long-term workforce strategy. The Chancellor mentioned, I think in his autumn statement, that this was something they were committed to producing in 2023 for the whole health service. When can we expect that?
Sir Chris Wormald: It is exactly as the Chancellor said. It was in the Budget, actually, where he said “shortly”.
Q141 Sarah Olney: How long is that?
Sir Chris Wormald: As I said before, I am not going to add or subtract from what the Chancellor said. We are expecting it shortly.
Q142 Chair: We would expect you to know a little bit more than “shortly”, given that it is in your remit, not the Chancellor’s directly.
Sir Chris Wormald: I have nothing to add to my previous answer. That is the timing the Government has set out, and I don’t have anything to add to it at the moment.
Q143 Chair: This calendar year?
Sir Chris Wormald: You would expect so, yes.
Chair: Okay, we’ve narrowed it down to the next eight months. That is some miracle.
Q144 Sarah Olney: Obviously, the huge pressure at the moment is the backlog in elective care. Given that that is the current pressure, but we are looking more long term with the workforce strategy, is there a danger that the needs of the mental health service are going to get lost in the overall demand? Particularly given the backdrop, as we have heard today, of the big increase that there has been in the mental health workforce, what are the risks in the strategy that future needs might get lost?
Sir Chris Wormald: I would hope not, for all the reasons that we have discussed today. The NHS has always been very clear that this is one of the biggest workforce priorities faced, even given the other pressures that you correctly mention. I think the best evidence of this is the fact that, despite all those other pressures, which are very well attested, the investment standard has been maintained and the proportion of NHS spending devoted to mental health has been rising, even given the pressures that we discuss at these hearings in urgent and emergency care, and in electives. So I think there is actually quite a good evidence base that people have continued to prioritise mental health, even given those other pressures.
As I said before, we recognise the story that the National Audit Office has told: there have been significant increases, there remain some significant gaps—as identified in the Chair’s favourite chart, figure 12—in particular aspects of the workforce and, despite the workforce increases, it is not currently keeping up with demand. I think the pressures in this area are understood by everyone. To go back to a point made earlier in the hearing, the costs across society and Government of getting this wrong are very high indeed. We all know the links between this agenda, employment, longer-term health, the cost to society and all those things. You put all that together. I would expect this to continue to be a priority for both the Government and the NHS going forward. The wider pressures you mention, and the trade-offs that will have to be made by everyone, are of course real, but I don’t think there is going to be any lack of seriousness given to the case that we have in front of us today.
Q145 Sarah Olney: Presumably, even though we do not yet exactly know when the workforce strategy is going to be published, there is already work ongoing to feed into it.
Sir Chris Wormald: Oh yes, there is an enormous amount of work, led by the NHS. While we will not say exactly what is going to be in what, the priority given to this area by my NHS friends is completely undiminished from what it has been over the previous years, and it is understood in Government in the same way.
Q146 Sarah Olney: Is the work that you have been doing already influencing decisions about recruitment and the allocation of funding, particularly to training?
Sir Chris Wormald: Within existing envelopes—I will hand over to Amanda, who is now responsible for this—I think figure 12 tells the whole story. There has been very strong investment in the mental health workforce, with expansions in all areas. In some areas, it is not as great as we need to see. Overall, despite some very spectacular numbers, it is not keeping pace with demand. As you would expect, the evidence that the NHS gives us fully reflects the picture you see in that chart, and it is not disputed by Government. As I say, there are no differences of opinion on what needs to be done. This is all about delivery.
Matthew Style: I just want to bring to life the point that Sir Chris made about the shared recognition from both the Government and the NHS of the particular priority we have given to addressing workforce needs in the mental health workforce, in advance of the long-term workforce plan. Within the changes to the student support arrangements that the Government have made, there is specific, targeted financial support for students considering undergraduate nursing courses focusing on learning disability and mental health nursing. So there is additional support available to attract students into those courses. That is already our policy, and it is just one example of how we have recognised the pressures in those particular bits of the profession.
Q147 Sarah Olney: The Report refers to the fact that NHS England and Health Education England are going to be merging, and that is going to lead to a reduction in headcount. How will that affect the funding that is currently available both for people who want to start out on a course of study to become qualified in mental health nursing or other roles, and for people who are already working within the NHS and wanting to develop their skills?
Amanda Pritchard: Actually, HEE is now formally part of NHS England; that has happened very recently. The completely correct description that you have just given about the reduction in headcount applies to Health Education England and NHS England, and NHS Digital as well. We have actually merged five organisations into one, because the TDA and NHS Improvement are also included. Centrally, we have committed to a reduction of between 30% and 40% of the national headcount. That doesn’t at all affect the money that then flows through to frontline staff and training places. That is a completely separate endeavour.
Q148 Sarah Olney: But with that reduction, do you not think there is going to be any reduction in efficiency or effectiveness in ensuring that the funding is getting to the right places to fulfil your workforce needs?
Amanda Pritchard: What we would say, being straightforward about it, is that this is a major change that we are going through as an organisation. You can’t just take out 30% or 35%-plus of an organisation and think that is not going to have some level of disruption. I recognise this is not the first reorganisation that my colleagues have been through. They are behaving as you would expect—incredibly professionally, despite all of it.
We are clear that the ambition is to have an organisation that is actually better able to do what it needs to do for the future. Where there are synergies between what Health Education England in particular and NHS England in this example used to do, and we can do them better together, that is a real opportunity for us to put our workforce and our commitment to it at the heart of what we do. In the same way, the conversation we had about data illustrates how central the NHS Digital function is to what we are trying to do as we lead the NHS for the future. It is very disruptive now, and I don’t want to take away from that, but one of the reasons we are moving at pace and doing it so fast is to try to get to a place where we are seeing the benefits of that streamlined national infrastructure for delivery.
Matthew Style: It is important to add that, as part of the regulations to give effect to the statutory merger of Health Education England and NHS England, we have given commitments that we will ensure that we still have transparency about the amount of funding that goes into education and training, so you don’t lose that as a result of the merger of the organisations. We will report specifically on education and training within the overall NHS expenditure position. That is a really important safeguard.
Q149 Sarah Olney: Ms Murdoch, you offered a very effective analogy of a bathtub and the plug not being in. We have already talked about the impact of losing 12% of the workforce every year. What is your analysis of why people are leaving, and what is the NHS doing at a national level to try to combat that?
Claire Murdoch: At a national level, the main thing we can do is support local trusts and local systems, through and with regions, to ensure they really understand what the local stresses are in their organisations. It will not be just one set of reasons. We need to make sure that we understand why staff are leaving locally and take effective action there—our chief executive has already said that this is a big priority for her.
I have already mentioned the fact that in mental health, particularly nursing, we have an older workforce. We know that one of the structural reasons will be retirement, and making retire and return, and pensions, easy. Things like that are really important.
Q150 Chair: Can you be clear on that? Doctors come back and do locum work after they have retired; is that possible for mental health nurses?
Claire Murdoch: It is entirely possible.
Q151 Chair: Registration can be a challenge.
Claire Murdoch: Registration is maintained. Nurses have to revalidate every three years; that is for the NMC, the nurse and their employer. But it is entirely possible to make retire and return a lot easier, and some of the recent changes are doing that. There was an abatement rule, which gets very technical and is concerned with tax. That is above my pay grade, but, basically, we think that was driving some of our more skilled colleagues away from the NHS to where they could, for example, get their pension and work for an agency. The NHS needs not to lose that skill, and that is a possibility we are looking at.
People talk about flexibility, and I think we have to really encourage employers and colleagues across the country to think very differently about the kinds of contracts and working hours there are—I know we do that nationally. Part-time might be less convenient for an employer to juggle in the short term, but it is a lot more inconvenient if you lose a good staff member because you have not been able to accommodate it. There are all sorts of things like that, where our people directorate are very much seeking to share best practice across the country.
We see some areas where turnover is much slower. That might be geographic, for example, because there are not jobs elsewhere. But it will also be because of good practice. We did a piece of work nationally, just before covid, on retention in mental health settings. We are keen to resurrect that as well, to ensure that we really are sharing best practice across the base.
Q152 Olivia Blake: Just to follow up on that, if we grade them red, amber or green, how ready do you think ICSs are? Where do you think the majority of ICSs are in terms of supporting the mental health workforce, as you have just outlined?
Claire Murdoch: I don’t know, but my guess, since as chief exec I talk to so many ICS leaders, regional leaders and colleagues—and my own trust sits across three ICS boards—is that workforce will be really high on everyone’s agenda. That could be the stresses from industrial action, their vacancy rates or understanding why people are leaving, but I would be absolutely certain of that.
In mental health, I regularly meet with leaders across regions and ICSs to talk about what the big barriers and opportunities are. Workforce will always feature as something they are working really hard to innovate around. That might be setting up their own local workforce academies, looking at different supply routes, being a good anchor institution and drawing workforce from local communities. I would be astonished if workforce was not high on every ICS’s agenda. I do not know if our chief exec and medical director would state the same, but that is my experience.
Q153 Chair: We have done a recent report on ICSs, and we have some concerns about how well embedded they are, but we will leave that for now. It is something that we will keep an eye on when we look at them in future.
Claire Murdoch: It’s that workforce question particularly.
Chair: Thank you; that is very helpful.
Q154 Olivia Blake: How do you feel the mental health workforce will be prioritised over, for example, the oncology workforce, which is a big issue in my area at the moment?
Chair: Whatever you are doing centrally, Ms Murdoch, you cannot determine that because, as Mr Style said, there is an emphasis on local decision making.
Claire Murdoch: We can’t, but we measure the Long Term Plan, and the brilliant protection that has been given to the mental health standard, and we measure it alongside activity and growth in workforce. We have required local areas to produce their own workforce plan. We don’t dictate what their plan should be, but we do look at the triangulation of what we want to achieve by way of standards, outcomes and activity, workforce growth, and the investment. In the last three years it is true that all areas have been feeding up their workforce plans for us to look at.
We are really clear that if we do not see the workforce growth, it is very hard to think that we will just achieve all this additional activity through efficiency and the introduction of digital means. It is something we monitor very carefully and support nationally, but yes, we require services to have a mental health workforce plan that we can look at.
More importantly, they ask us for help with that as well—the sharing of new roles. I am very proud of the innovation in the sector around new roles, but our job is to ensure we are supporting systems in stealing from each other the best ideas.
Chair: There are interesting tensions here between central workforce plans and local ones, I think.
Olivia Blake: That was useful, thank you; that was very clear.
Chair: Thank you; Ms Morris.
Anne Marie Morris: Ms Murdoch, you referred earlier in your evidence—
Chair: Forgive me; sorry, I have skipped over the deputy Chair, who wanted to sneak in.
Q155 Sir Geoffrey Clifton-Brown: Thank you, Chair. I want to come in on this workforce issue. Ms Pritchard, HEE does a lot of really useful work on planning, recruitment, retention, education and training. It is merging with your organisation on 1 April. The Report tells us that you are planning a 30% to 40% cut in the workforce of that organisation. Given the problems that Ms Olney has just been talking about with Ms Murdoch on retention, is this really a sensible plan?
Amanda Pritchard: We were just talking about that a moment ago. That reduction in headcount applies to the whole of what is the combined, now, new NHS England. That includes HEE and NHS Digital, as well as the bits that used to be NHS Improvement and the TDA.
What we have done, very rapidly, is take the opportunity to review the functions across the whole of NHS England and to look—very much in the spirit of where we are going with ICSs—at what needs to be done at a local level and what most sensibly needs to be done in the national organisation, which includes our regional elements. Where there is an opportunity to streamline that, that is clearly what we are designing into the new organisation.
Just to pick up your specific point about HEE, we already had a workforce directorate within NHS England. What we now have is that the person who is both the national chief workforce and training officer was the chief executive of HEE—so, Navina Evans now sits across what is the old HEE and the old NHS England workforce directorate. What she has done is use her expertise and lots of engagement from within the organisation—and externally as well—to design a workforce function that brings in all the brilliant stuff that HEE did, and continues to do, but she has absolutely identified those opportunities to streamline and make sensible use of staff across both to do it within a more reduced headcount.
Q156 Sir Geoffrey Clifton-Brown: I hear what you say—and, of course, we have not seen the workforce plan yet, which makes life very difficult for all of us—but clearly, whether it is in the field of mental health or health more generally, this retention issue is a really important one. You can make all the efforts you like—it is like Ms Murdoch’s issue of running the bath with the plug out at the beginning, which was a very good analogy, if I may say so. If you are not retaining the staff, you will have to work twice as hard to recruit more staff. I wonder whether actually cutting the headcount of the very people responsible for planning retention makes any sense.
Amanda Pritchard: I suppose the distinction here is also about what needs to be done locally and what makes sense to be done nationally. What we do know is, notwithstanding all the discussion we had earlier about the bigger national issues around pay and so on, the thing that really matters to individuals locally is local teams—the experience they have within their organisations, the support available to them locally, how many staff they work with on a shift on an everyday basis etc.
While I think that nationally, there is a hugely important role to play in identifying where the national support offers need to be—including things like data collection, so that we can spot where there might be local challenges and some of the sharing of best practice that we have talked about—actually what we could never attempt to do, and should not do, nationally is try to run what is going on on the ground in every part of the health service across the country. What we need to do is support local leaders to do it as well as they possibly can.
Q157 Sir Geoffrey Clifton-Brown: My own trust has a particular problem with retention. I think I know the reasons why, and I think that they need national advice. Okay, it might be among some of the people who need the advice most—I don’t know—but there is clearly a function for a national body to give some of this advice.
Amanda Pritchard: I absolutely agree. I think that having a smaller organisation in the way we described will make our organisation better, better able to support local organisations to do what they need to do and better able to empower ICSs to do what they need to do. I guess the reassurance that I would offer is that we will keep this under constant review. If it looks like we have gone too far in one area and not far enough in another, as this runs through, we will absolutely course-correct.
Professor Powis: I think the Chair referred earlier to the tension between what you do nationally and what you do locally—let us say a balance, rather than a tension. Clearly, with the establishment of ICBs as statutory bodies, it is quite right that we assess that balance and make sure that we are ensuring that ICBs—as I think we have all agreed—have the biggest chance of being successful as possible. We do want to allow local systems to make their own decisions, but we absolutely recognise what you are saying, Sir Geoffrey, that that also requires a balance, because they need the sort of support that we can give nationally and regionally. Claire, again, has demonstrated how we think about that balance throughout a lot of the answers she gave, but you are absolutely right that that balance is critical. We need to reset it, but it needs to be right.
Sir Geoffrey Clifton-Brown: To comment on your answer, it ought to be a partnership, rather than tension. We are all working in the same direction, surely.
Professor Powis: Yes, exactly. That is why I think it is important.
Q158 Anne Marie Morris: Ms Murdoch, parity of esteem is still not defined. How can you therefore measure success?
Chair: You touched on this earlier, but perhaps you will expand.
Claire Murdoch: We did, and I jotted a few points down. It is about equal investment all the while that we know it is needed. That helps. We can translate that into workforce and therefore treatment. So, it is about looking at some fairness and equality in how we invest in health services, and seeing mental illness on just as serious a footing as, for example, cancer or other major disorders. That is important.
It is about making sure that we have got the data and that we are able to see things like—as the Hewitt review said recently, for example—the waiting lists for mental health being treated with the same urgency or importance as we treat the other waiting lists. That is right. It is about access and waiting times. We have talked about what we are doing to roll out the clinical review of standards, and publishing that.
Within mental health itself, it is very much about making sure that you get the treatment that you need when you are unwell in a timely way—in order, actually, to keep you in work or in school, and to have you being a productive member of society. All the things we said earlier are really important, as we have them for physical health.
Q159 Anne Marie Morris: Why is it not being defined?
Claire Murdoch: I think we should define it—
Anne Marie Morris: All you say is good stuff. The NAO Report has suggestions for the sorts of things that should be included, some of which you have mentioned, but some you have not. Surely, without a definition—
Sir Chris Wormald: Shall I come in?
Anne Marie Morris: Sir Chris. You are going to have the answer.
Sir Chris Wormald: To spare Claire, I think this was aimed at us, rather than at the NHS. That is an NAO recommendation. I completely understand why it has recommended it, and we will certainly consider that recommendation carefully. It is not the Government’s current position, and I will set out why, but it is a debateable argument. I will set out the other side of the case.
Parity of esteem is both a set of targets and a concept. There are definite dangers in trying to tie what it means down to a sort of algorithm—“If you hit this set of targets, then we declare parity of esteem”—so it is locked in the words. It is very important that we have targets, although the NAO has reported against them, and we need to continue to do so, but we want parity of esteem to mean more than that. It is not just about mental health services—Stephen may want to add to this as well—but also about how the entire NHS thinks about mental health and physical health. What does a GP think when somebody walks into their consulting room with both a mental health and a physical health condition? On the point that Sir Geoffrey made earlier, it is about how employers and wider society think about mental health. A number of those issues have come up in the hearing.
There are therefore dangers in trying to get it down to a sort of algorithmic solution, because that puts all the pressure on mental health services. That is not to say that we don’t have to have clear targets. Just like in every other aspect of health, we do, and they are set out in the Report. As you have discussed with us already in this hearing, we need to move those targets on, and they need to become more specific about outcomes, but it is debatable whether a very strict definition would be helpful. We will take it away and think about it, because the NAO made a serious recommendation, which we will consider, but my point is that it is not a straightforward argument.
Chair: There is a danger that we are getting a bit intellectual about this.
Q160 Anne Marie Morris: Well, I hear the argument, but I don’t agree with it.
Sir Chris Wormald: Some people don’t. What I am saying is that we will think about it, but there are two sides to the argument.
Q161 Anne Marie Morris: There are always at least two sides to any argument.
Chair: We wouldn’t all be here if there weren’t.
Sir Chris Wormald: The bit I think we all agree on is that we need to go on having very clear targets for what we are trying to achieve in mental health. We agree on the steps towards parity of esteem, and that those targets need to evolve in the way that your questioning led us to earlier.
Q162 Anne Marie Morris: That’s all we want. Indeed, Sir Chris, you said that what you want is not just a set of targets. Therefore, what we want is something very clear. What is the objective and what are we trying to achieve? That does not mean that we are then constrained just to setting targets, meeting them and ticking a box. That is a very narrow way of looking at it. I am delighted that you are going to go away and look at it.
Chair: We look forward to your response.
Sir Chris Wormald: We may be more in the same territory than I had imagined. Do we need to be clear about what we are trying to achieve? Yes, but it is as much about a way of thinking as it is about targets. That is my point, and I think you may be agreeing with that.
Professor Powis: I think it is about the components of many of the things we have talked about. We started off with data—are we are ensuring that data sharing and access to data is on an equal basis to physical health? We have talked about the workforce, standards of services, attitudes to mental health and early prevention. It is all those things.
Chair: And equality.
Professor Powis: I know the Royal College of Psychiatrists have provided you with their thoughts on this, many of which we agree with. That is notwithstanding the debate on whether we need the definition. We understand the components, and it is about equality of all those things with physical health.
Anne Marie Morris: Good to hear, but without the definition, it is very hard to ensure it is actually met and delivered on.
Chair: Thank you very much, Ms Morris.
Q163 Sarah Olney: The pressure on elective services is obviously a clear priority. We have done previous sessions in this Committee on that. Ms Pritchard, how are you going to ensure that mental health doesn’t become a lower priority for the NHS—in particular, for local ICBs?
Amanda Pritchard: We have picked up some of this before. That is why we wanted to be as explicit as we were in our slimmed-down planning guidance for this year about the priority that we still see as being absolutely critical for mental health services, and for learning disability services and services for autistic people. That—in NHS operational delivery speak—sits as is the set of things that we have just said to the NHS are the priorities we will be monitoring over the course of this year.
That doesn’t mean that there are not a huge number of other really important things. Part of the ICS opportunity is that it can think much more widely about what matters to local populations and design around that. It is not to narrow down the opportunity to do that kind of bottom-up thinking; it is about being really clear about what we are saying nationally about the priorities agreed with the Government. Within that, the priority around spending the money in the way that we have just discussed is an incredibly important safeguard to make sure we and colleagues in ICSs and on the frontline don’t take our eye off the ball of the importance of this agenda.
Q164 Sarah Olney: Can you provide us with an assurance that mental health funding is not going to be impacted?
Amanda Pritchard: Absolutely, and that is the commitment that we have made. Again, we have the support to protect the mental health investment standard.
Chair: Thank you very much.
Q165 Olivia Blake: Now that there will be only six mandated national objectives for mental health, how are you going to hold local areas to account for improvement in their area, Ms Pritchard?
Amanda Pritchard: As I say, those are the things that we have said are the absolute, must-do headlines, but every organisation and every ICS also carries a range of statutory responsibilities for things such as the quality of their services, achieving their financial plans, things that we would expect them to do around workforce, and so on. I am always hesitant to say that we have been really clear or really limited. We are trying to be very disciplined about saying what the headlines are, but there is clearly a much more complex set of responsibilities that statutory organisations carry.
In terms of your particular point about quality, one of the things that feeds into that would be CQC reports and their findings, and where they have reflected on areas where they would expect to see improvements. That continues to be something that we would obviously expect and, jointly with the CQC, be holding local systems to account for continuing to deliver.
Our sense at the moment is that to build on the progress we have made with the Long Term Plan, to catch up where we have seen disruption and to ensure that we are continuing to give it the priority we need, we need to be really clear about the priorities still being as relevant as they ever were on the Long Term Plan. But the overall responsibilities for continuous quality improvement and so on obviously remain as true in mental health as they are in any other aspect of NHS services.
Q166 Olivia Blake: Given what you were just saying, do you feel that this will be a move for NHS England to be a bit more reactive to other inputs?
Amanda Pritchard: I think it just reflects the partnership working that we have had for a long time but that we increasingly see very much as the way that we work: mirroring the way that local systems work and the way that we work with partners, whether partners in Government, in other arm’s length bodies such as the CQC or in voluntary sector partners. That remains central to the way that we do our business.
Q167 Olivia Blake: In a similar vein to Sir Geoffrey’s questions about workforce, how concerned are you by the NAO survey, Ms Murdoch? Most ICSs felt that they did not have the capacity, resources or staff to improve mental health services.
Claire Murdoch: I would be very concerned by that, because we are putting £2.3 billion in. We have grown the workforce by 22%, and by 40% in child and adolescent services. All that is hard—nobody said this would be easy, of course. I would be concerned if so many really felt that they did not have the opportunity.
We have also been doing a lot of development work with local provider collaboratives, and we are giving a lot more money and responsibility to those collaboratives. They are part of ICSs, and they are clinically led. They have been doing some incredibly innovative work on how to spend the money differently, how to attract different workforce, how to retain differently and how to change the pattern of care. There is some really good work ongoing there.
Of course, there is that ever-present concern about workforce. We look at our vacancy levels across the NHS, and it is just something that they need to be resolutely focused on. We are collecting a lot of information. I am hopeful that the long-term workforce plan will be a real support to mental health in this arena—in fact, to the whole of the ability of the NHS to plan workforce, develop new roles and monitor the information. I remain hopeful about the publication of that report, and what is in it, as an assistance to ICSs and national programmes such as my own.
Q168 Olivia Blake: I completely take the point about frontline staff, but I think the concern was around ICB capacity to implement the changes.
Claire Murdoch: They are very new organisations—they will be at different levels of skill, expertise and maturity—but they are all really on this journey, I think, very rapidly. Certainly for my programme, Navina Evans and NHS England as a whole will be there to support them on this. It is a top priority.
Some are doing some really interesting work—fascinating and important work with local communities on different routes into work, widening participation and different routes to come into NHS careers. There is already some great practice out there that we need to make sure we are moving fast to share across the country. But I would certainly be concerned if any ICB said, “We can’t do workforce.” I just do not think they would. It is hard.
Q169 Chair: The NAO has done this useful survey; are you planning to replicate this sort of work?
Amanda Pritchard: We talk to ICBs formally at least once a month as a group. In fact, from this afternoon I am personally meeting all 42 of them over the course of the next 10 days to see where they have got up to with the planning process for this year, so this is one of the areas that we will be picking up on. We have very regular dialogue with them.
I just wonder—perhaps I should have clarified this before the hearing—whether all ICSs have answered these questions in quite the same way. I think you might answer differently if you thought you were answering just for the board itself, or for the whole of the NHS services within your ICS, or indeed if you were asking a question that is a bit more about the structures that exist. When we think about ICSs, we are certainly not just thinking about the small number of people who sit on a board or in a committee. Actually, we are thinking about all the organisations that work together to comprise that ICS.
Q170 Chair: Nevertheless, it throws up some concerns.
Amanda Pritchard: Yes, but I think that is where Claire’s point about the mental health collaboratives is so important, because actually that is a really important source of expertise, both clinical and in other ways, which of course the ICSs have to draw on to help them with this agenda.
Q171 Olivia Blake: Sir Chris, is the planned change towards having a strategy more focused on major conditions and away from the 10-year strategy on mental health a downgrading or an integration of mental health?
Sir Chris Wormald: The latter. We have had this debate across various topics about the major conditions strategy. As I said earlier, I think one of the absolute key things is that interrelationship between mental health conditions and physical health conditions, and the numbers of people who have both. That is one of the key reasons for having an integrated strategy across major conditions. Matt, do you want to add to that?
Matthew Style: I think it is a real opportunity to bring to life precisely the factors that Sir Chris has set out and to make a reality of that integration. The proof will be in the pudding, as it were, and you will be able to see whether that has been successful in due course.
Professor Powis: I am happy to say a few words here because I am the executive lead from the NHS, working with Ministers in the Department on the major conditions strategy. In fact, I was at a roundtable yesterday, hosted by the Secretary of State, for voluntary-sector organisations across all the conditions, together with some professional bodies such as the Academy of Medical Royal Colleges.
I think it is fair to say that there is a recognition that working in disease and condition silos is not always the best way forward, and there is a real opportunity to think about how these conditions are brought together. The reality is, as we have talked about today, from the patient and individual person perspective you are often dealing with more than one condition at the same time. That is the reality.
Chair: Going round the out-patient loop of hell.
Professor Powis: We need to think about this in a person-centred approach rather than in a disease or condition-centred approach.
Q172 Chair: It is difficult when you have medical professionals who are now very specialised, though.
Professor Powis: Yes, and the workforce bit of that—moving towards a more generalist side—is important, but how we provide the services in a more holistic way is another part of that, as indeed is how the voluntary sector and charities think about this in a joined-up way. I know that is one of the things the Richmond Group—the group of leading charities—is thinking about, too. So there are lots of opportunities and there is lots of sense in thinking about this in the round and the whole rather than thinking about this in the individual silos for individual conditions.
Q173 Olivia Blake: That sounds like a very sensible approach. The key question is: how will we monitor to ensure that mental health does not disappear in the process?
Sir Chris Wormald: I think that goes back to some of the conversations that we have had already. The investment standard remains incredibly important, and measuring against the very specific targets remains very important. This is all about balance, really. To take your previous example, of course we need to go on having people who are absolute specialists in particular conditions, and of course we need people who can deal with the whole patient as well as the individual conditions. What my colleagues here do—Stephen in particular—is balance up those two sets of needs and try to reconcile them.
I think it is the same on the issue that you have just raised. We do need to go on having some very specific and measurable things on mental health, particularly around capacity and quality and all the things that Claire has been driving. But then we need to ask ourselves the question: are we actually improving the life of the whole patient as opposed to picking off particular things? This is all about finding the right balance between the two.
Q174 Olivia Blake: Sir Chris, do you feel that the Government is using all the tools at its disposal and doing enough to promote mental health and prevent future mental health problems?
Sir Chris Wormald: It is impossible to say enough on any of these subjects. Within mental health services, as I said at the beginning, the National Audit Office has correctly identified where huge progress has been made and where the pinch points are where we need to do more, so I will not repeat any of that.
I think we have made a fair amount of progress on the wider issues in respect of how mental health relates to other services. I am sure you have seen this in your own constituencies: 10 or 15 years ago it was not even discussed or mentioned, but we have moved a very long way in terms of mental health. Would anyone say that that is mature across the country? I don’t think anyone would really. We can pick out, as the Chair did earlier, some brilliant examples of good practice, but I do not think the whole system has reached maturity.
I do think that, as the Report sets out, we are heading firmly in the right direction, but I don’t think anyone would think we have got to where we need to have gone to have the types of services and the wider culture around mental health that we would want.
Q175 Chair: You talked about the major conditions strategy; when do you expect to publish that?
Matthew Style: We expect the interim conclusions around the summer, with a longer timetable for the final report.
Q176 Chair: I can imagine it will take quite a while. How does it integrate with the workforce plan that is coming shortly? If you have a major conditions strategy, there must be an impact on the workforce plan. It is a circular thing, isn’t it?
Matthew Style: The two teams are working very closely together.
Chair: We’ll try every which way; we’re not going to—
Sir Chris Wormald: You never declare an end state on any of these issues.
Chair: No—we appreciate that you are painting the Forth Bridge.
Professor Powis: I think many of the themes that you would expect to see in the workforce plan are themes that will be considered in the major conditions strategy. For instance, we have just talked about the balance between generalist training and specialist training. That is something that we will need to think about in the long-term workforce plan, and indeed are, and of course it is something that goes to the heart of when you think about a set of conditions together.
Q177 Chair: I sense some tension on the workforce plan, which we cannot quite get to the bottom of.
I want to touch quickly on the fact that a number of people are leaving and the issue of retention. Figure 14 on page 51 highlights the figures: quite shockingly, staff sickness absence nearly doubled in a decade—well, not quite, but it went from 18% to 30%. That was the percentage of days lost from the mental health workforce “due to psychiatric reasons”. So within the mental health workforce, nearly a third of the days lost were because of psychiatric reasons. Isn’t that a bit of an indictment of a system that is supposed to support people’s mental health? Are there any plans to support the staff better? Professor Powis? Ms Murdoch?
Claire Murdoch: We know that the two biggest drivers of sickness among our own staff across the NHS are musculoskeletal problems and mental health problems.
Chair: So you are very aware of that.
Claire Murdoch: We are very sighted of that. I also think that during covid the whole NHS talked much more about resilience, staff support and staff welfare. Again, I think we are all hoping that a real legacy of covid will be that we do not step back from that. A huge amount of work is now ongoing about supporting staff in the workplace. I stress that we absolutely know about the need for good supervision, a good manager, flexibility and a good debrief when traumatic incidents have happened at work. Healthcare is traumatic.
Q178 Chair: It isn’t rocket science, is it? This is what happens with any good employer.
Claire Murdoch: Exactly. Navina Evans and I am sure our chief exec—we really need to focus on these basics that keep an individual and a team healthy and well, as well as, of course, through occupational health and other routes, being able to fast-track staff for assessment and support, which we are doing. An awful lot of that good mental health resides within teams and good processes. It is something that we have done a tremendous amount of work on.
Q179 Chair: So it is a priority for you.
Professor Powis: Yes. We talked about employers earlier, because you asked a question about employers in the round. The NHS, in its various organisational components, is the major employer in the country so, as you would expect, we need to have a focus on this. We need to do better. As Claire said, we had a real focus on it during covid, for obvious reasons, but the key now is to sustain that focus on the wellbeing of staff and getting support into staff. That is what we will be doing through our local organisations, but obviously with the appropriate support from the national and regional teams too.
Q180 Chair: I will come to you in a moment, Professor Powis, but I wanted to just touch very briefly on the funding. We talk about parity, but about £12 billion is spent on mental health services, which is only 9% of the NHS budget. The capital gap is wide—we touched on that earlier, Mr Style—and it is growing. Figure 15 highlights the figures.
If there is real parity of esteem, why are the figures so different for mental health and the rest? Obviously, some of the physical facilities will support both but, particularly on the capital, there is quite a widening gap. I imagine that it is not as acute immediately, or it does not seem as acute, but if you are consigned to a ward as an in-patient and your facilities, as one of our witnesses said on Monday—from the CQC, indeed—are two showers between 19 people, that is not conducive to people’s recovery. Where is the priority on capital investment? It is all very well to say that it is local, Mr Style, but that is not any good if you do not have any money to spend, is it? Sir Chris?
Sir Chris Wormald: No one is going to argue about there being overall pressures on the NHS capital budget and that those flow out into mental health as well as into physical health. You would be asking us some quite similar questions if we were discussing a range of physical health issues and the capital needs there. Overall, looking at capital and recurrent together, we do want to see more spent on mental health. That is the whole purpose of the investment standard: to see that percentage growing.
Mr Style has already described the position on capital. We do want to see more local decision making across the entire capital budget. We do want more of those difficult trade-off decisions—there is no getting away from it: they really, really are—taken at a local rather than national level, but as I say, the overall policy, locked in the investment standard, is that we do want to see those numbers rising.
Q181 Chair: That is a good aspiration, but it is not your job to find the money. We recognise those challenges.
Sir Chris Wormald: No, but in this case—and the NAO clearly reports on it—we have actually been hitting the investment standard, so this an area where in the Long Term Plan we set out an aspiration to change the balance, and my colleagues here have delivered it.
Q182 Chair: Finally, Professor Powis, I want to get a quick perspective from you. We have talked a lot about the pandemic’s impact on mental health, but obviously we are going through other challenging times now with people very much worried about money, food prices going up and just generally surviving. We see this in our surgeries: people are really hammered, because when you have little financial resilience, that can have a very big impact on your mental health. How are you factoring in those external impacts? We heard very good evidence on Monday about how mental health needs to be seen as a societal issue, not just a health issue. Where does your role fit into influencing Government? Obviously, you have a key role in Government as a whole, not just in NHS England.
Professor Powis: Yes, and I know that this is something the Chief Medical Officer also talks about. Going into the winter, Chris spoke a lot about the effects of the cost of living rises that we have seen recently on people’s willingness to heat homes. Obviously, the Government made a response to that in the autumn, but there are wider issues as well.
Claire also touched on it earlier when she talked about eating disorders and watching carefully what was coming out of the pandemic and whether we were going to see the incidence of those disorders falling or staying at a stable level. We do look at it very closely, we do factor it into our planning going forward, and we are very aware that those wider societal issues in respect of both mental and physical health are a really important part of what we need to consider at the moment in terms of planning services.
Q183 Chair: Do you feed your thoughts into Government? Obviously, it is a cross-Government issue.
Professor Powis: Yes, we do. That is a responsibility for us and it is also a key role for the Chief Medical Officer, and I know he is not backward in coming forward and advising Government colleagues.
Chair: Absolutely, and more power to your elbow on that. I would love to go into that more, but we are short of time—we have already run over. I thank you very much indeed for your time and I wish you the best in achieving what is a very challenging target.