The Tories are ramping up the price of Clegg's boundary sabotage

Keeping the moribund review alive is part of a wider strategic game of coalition negotiation.

The Guardian has an interesting story this morning on Conservative attempts to resuscitate plans to redraw parliamentary boundaries. Unnamed Tory sources have suggested recruiting MPs from smaller parties – Democratic Unionists, Welsh and Scottish Nationalists – to help tip a vote in favour of redrawing constituency lines ahead of the next election, now that the Lib Dems have demonstrated their intent to kill the idea.

The other parties sound pretty tepid towards the idea, but they leave some room for crude pork-barrel bargaining. That is how small parties roll if they want to get things done.

Senior Tories are clearly desperate to salvage the boundary changes, which could make a difference of as many as 20 seats in their favour. But I sense that, amid all this frantic reaching down behind parliamentary sofa cushions for spare votes, there is a recognition that the 2015 general election will be conducted on existing boundaries. The candidate selection process is under way, strategists need to think about targeting resources, incumbents want to get on with the business of digging themselves in for a defensive battle.

So what is really going on here? Partly, the argument is about preserving the boundary review from total oblivion. A crafty manoeuvre in the Lords has meant that Labour and Lib Dem peers could kick the whole thing beyond 2018. Six years hence is as good as never in politics.

So the Tories will at least want to put pressure on Nick Clegg to find some compromise that means the changes can be at least settled in principle with implementation only deferred until just after 2015.* That way the Lib Dem leader gets to retain the glory of the bloody nose he inflicted on Cameron as revenge for the PM’s failure to secure reform the House of Lords but the Tories get the reforms they badly need for the long term onto the statute book.

Leaning on Clegg certainly seems to be the motive for leaking and briefing the Tories’ various plans to keep the boundary review alive. Not so long ago a far-fetched idea surfaced according to which the Lib Dems might reverse their opposition to the new constituencies in exchange for state funding of political parties. It was a non-starter and Clegg’s allies hosed it down with scorn. The whole purpose of floating it at all appeared to be to maximise Lib Dem discomfort and flush out some measure of their biddability.

After all, the Tories have been in coalition for long enough to know the Lib Dems are up for negotiation on most things. Downing Steet may initially have underestimated Clegg’s determination to retaliate over Lords reform but they know there will be other things he wants and things he needs to show his party and his country as prizes. The Tories must also know, however, that it would take some quite spectacular policy bauble - as yet unimagined - to permit Clegg to turn around and say, on second (technically third) thoughts, he is backing the boundary changes again.

There are parallel policy negotiations and horse trades going on all the time. In the run-up to the Autumn Statement – a mini-review of spending priorities due on 5 December – those talks are getting more urgent and heated. It is worth noting, in that context, that one effect of briefing that the boundary changes are not yet dead is to remind everyone of their importance to the Tories and, by extension, the heavy penalty Clegg has inflicted for the loss of his precious elected Senate. In other words, these stories and rumours about boundary deals ramp up the sense of Tory grievance, which is one way to shift the balance of power in various other negotiations. "Sorry Nick", say Cameron and Osborne. "But you hit us so hard on that boundary changes thing, you’re not seriously going to kick up a fuss over these welfare cuts/pesky windmills etc. are you? Be reasonable!"

I don’t doubt that the Cameron and Osborne are determined to reform parliamentary boundaries. Nor do I doubt that they’d like it to happen in time for the next election. It won’t and they must know as much. They can, however, make absolutely sure the Lib Dems know that, in smashing this most precious Tory policy, they have used up a very large chunk of their coalition bargaining chips and are in no position to come asking for policy favours.

*This distinction is a bit of a red herring as it transpires. See first comment below.

Update: A senior Lib Dem source has been in touch.

 

Nick Clegg pledged to veto the proposed boundary changes after David Cameron abandoned plans for House of Lords reform. Photograph: Getty Images.

Rafael Behr is political columnist at the Guardian and former political editor of the New Statesman

Photo: Getty Images
Show Hide image

British mental health is in crisis

The headlines about "parity of esteem" between mental and physical health remain just that, warns Benedict Cooper. 

I don’t need to look very far to find the little black marks on this government’s mental health record. Just down the road, in fact. A short bus journey away from my flat in Nottingham is the Queens Medical Centre, once the largest hospital in Europe, now an embattled giant.

Not only has the QMC’s formerly world-renowned dermatology service been reduced to a nub since private provider Circle took over – but that’s for another day – it has lost two whole mental health wards in the past year. Add this to the closure of two more wards on the other side of town at the City Hospital, the closure of the Enright Close rehabilitation centre in Newark, plus two more centres proposed for closure in the imminent future, and you’re left with a city already with half as many inpatient mental health beds as it had a year ago and some very concerned citizens.

Not that Nottingham is alone - anything but. Over 2,100 mental health beds had been closed in England between April 2011 and last summer. Everywhere you go there are wards being shuttered; patients are being forced to travel hundreds of miles to get treatment in wards often well over-capacity, incidents of violence against mental health workers is increasing, police officers are becoming de facto frontline mental health crisis teams, and cuts to community services’ budgets are piling the pressure on sufferers and staff alike.

It’s particularly twisted when you think back to solemn promises from on high to work towards “parity of esteem” for mental health – i.e. that it should be held in equal regard as, say, cancer in terms of seriousness and resources. But that’s becoming one of those useful hollow axioms somehow totally disconnected from reality.

NHS England boss Simon Stevens hails the plan of “injecting purchasing power into mental health services to support the move to parity of esteem”; Jeremy Hunt believes “nothing less than true parity of esteem must be our goal”; and in the House of Commons nearly 18 months ago David Cameron went as far as to say “In terms of whether mental health should have parity of esteem with other forms of health care, yes it should, and we have legislated to make that the case”. 

Odd then, that the president of the British Association of Counselling & Psychotherapy (BACP), Dr Michael Shooter, unveiling a major report, “Psychological therapies and parity of esteem: from commitment to reality” nine months later, should say that the gulf between mental and physical health treatment “must be urgently addressed”.  Could there be some disparity at work, between medical reality and government healthtalk?

One of the rhetorical justifications for closures is the fact that surveys show patients preferring to be treated at home, and that with proper early intervention pressure can be reduced on hospital beds. But with overall bed occupancy rates at their highest ever level and the average occupancy in acute admissions wards at 104 per cent - the RCP’s recommended rate is 85 per cent - somehow these ideas don’t seem as important as straight funding and capacity arguments.

Not to say the home-treatment, early-intervention arguments aren’t valid. Integrated community and hospital care has long been the goal, not least in mental health with its multifarious fragments. Indeed, former senior policy advisor at the Department of Health and founder of the Centre for Applied Research and Evaluation International Foundation (Careif) Dr Albert Persaud tells me as early as 2000 there were policies in place for bringing together the various crisis, home, hospital and community services, but much of that work is now unravelling.

“We were on the right path,” he says. “These are people with complex problems who need complex treatment and there were policies for what this should look like. We were creating a movement in mental health which was going to become as powerful as in cancer. We should be building on that now, not looking at what’s been cut”.

But looking at cuts is an unavoidable fact of life in 2015. After a peak of funding for Child and Adolescent Mental Health Service (CAMHS) in 2010, spending fell in real terms by £50 million in the first three years of the Coalition. And in July this year ITV News and children’s mental health charity YoungMinds revealed a total funding cut of £85 million from trusts’ and local authorities’ mental health budgets for children and teenagers since 2010 - a drop of £35 million last year alone. Is it just me, or given all this, and with 75 per cent of the trusts surveyed revealing they had frozen or cut their mental health budgets between 2013-14 and 2014-15, does Stevens’ talk of purchasing “power” sound like a bit of a sick joke?

Not least when you look at figures uncovered by Labour over the weekend, which show the trend is continuing in all areas of mental health. Responses from 130 CCGs revealed a fall in the average proportion of total budgets allocated to mental health, from 11 per cent last year to 10 per cent in 2015/16. Which might not sound a lot in austerity era Britain, but Dr Persaud says this is a major blow after five years of squeezed budgets. “A change of 1 per cent in mental health is big money,” he says. “We’re into the realms of having less staff and having whole services removed. The more you cut and the longer you cut for, the impact is that it will cost more to reinstate these services”.

Mohsin Khan, trainee psychiatrist and founding member of pressure group NHS Survival, says the disparity in funding is now of critical importance. He says: “As a psychiatrist, I've seen the pressures we face, for instance bed pressures or longer waits for children to be seen in clinic. 92 per cent of people with physical health problems receive the care they need - compared to only 36 per cent of those with mental health problems. Yet there are more people with mental health problems than with heart problems”.

The funding picture in NHS trusts is alarming enough. But it sits in yet a wider context: the drastic belt-tightening local authorities and by extension, community mental health services have endured and will continue to endure. And this certainly cannot be ignored: in its interim report this July, the Commission on acute adult psychiatric care in England cited cuts to community services and discharge delays as the number one debilitating factor in finding beds for mental health patients.

And last but not least, there’s the role of the DWP. First there’s what the Wellcome Trust describes as “humiliating and pointless” - and I’ll add, draconian - psychological conditioning on jobseekers, championed by Iain Duncan Smith, which Wellcome Trusts says far from helping people back to work in fact perpetuate “notions of psychological failure”. Not only have vulnerable people been humiliated into proving their mental health conditions in order to draw benefits, figures released earlier in the year, featured in a Radio 4 File on Four special, show that in the first quarter of 2014 out of 15,955 people sanctioned by the DWP, 9,851 had mental health problems – more than 100 a day. And the mental distress attached to the latest proposals - for a woman who has been raped to then potentially have to prove it at a Jobcentre - is almost too sinister to contemplate.

Precarious times to be mentally ill. I found a post on care feedback site Patient Opinion when I was researching this article, by the daughter of a man being moved on from a Mental Health Services for Older People (MHSOP) centre set for closure, who had no idea what was happening next. Under the ‘Initial feelings’ section she had clicked ‘angry, anxious, disappointed, isolated, let down and worried’. The usual reasons were given for the confusion. “Patients and carers tell us that they would prefer to stay at home rather than come into hospital”, the responder said at one point. After four months of this it fizzled out and the daughter, presumably, gave up. But her final post said it all.

“There is no future for my dad just a slow decline before our eyes. We are without doubt powerless – there is no closure just grief”.

Benedict Cooper is a freelance journalist who covers medical politics and the NHS. He tweets @Ben_JS_Cooper.