You get appointed as a minister with no training about how to use power to achieve what you want,” says former Liberal Democrat MP and care minister Sir Norman Lamb.
“So you essentially learn on the job and I am quite clear that I became more effective as a minister as I did the job. I realised that you have to give as much focus to implementation as you do to the initial policy.”
It was nearly 10 years ago in December 2012 that Lamb wrote the ambitious foreword to Transforming Care, the coalition government’s response to the Winterbourne View abuse scandal.
The programme aimed to move people out of assessment and treatment units (ATUs) such as Winterbourne and into homes in communities. It was part of a “push for change”, says Lamb.
Today, however, the 64-year-old admits he was naive about the approach: “We did Transforming Care as a concordat. We got everyone to sign up to it – NHS England, royal colleges, local authority representatives and so on.
“And I thought that if people had committed to a course of action they would take steps to implement it. I didn’t think that institutions would so readily commit to something and then just ignore it.”
What does he think of how much change there has been? “Not nearly enough,” he replies. “Transforming Care was the most frustrating issue I had to deal with as a minister because of the inertia in the system and the resistance to change persists in far too many places.”
A central target – to get everyone out of ATUs and similar provision within 18 months – was not met. It has still not been met. Lamb says that, frustratingly, change has been only slow and incremental.
While many people moved out of ATUs, others moved in and the overall figures seem to have plateaued. Around 2,000 people remain in these units, compared to an original 3,400.
Why is this? Lamb points out that community support has been underfunded and eroded by consecutive governments. He describes a system that financially incentivises institutions to keep beds filled, while the same institutions employ the psychiatrists who decide whether someone needs to stay in a bed.
“There are lots of things that undermine our ability to get people back in the community,” he says.
Some people’s lives did get better. Lamb says: “There are a lot of people who are now living independent lives who hadn’t been before that, who benefited from that whole initiative but, fundamentally, we haven’t properly confronted the institutionalised model of care which persists in far too many places.”
Concept versus practice
I ask Lamb why he thinks care and treatment reviews (CTRs), introduced in 2015, have not always delivered the change they seemed to promise. “I am not sure… they’re a good idea in concept.”
He tells me a story about how, as a minister, he initiated a review for a 15-year-old autistic girl stuck in a negative spiral of isolation in an ATU with frequent use of physical restraint.
The review led to a move to a more person-centred provider. Lamb saw her again two years later. She had not been restrained once and was leading a much more positive life.
If the people undertaking care and treatment reviews don’t believe in the principle of freedom, they will not work
But results are not always so life changing. “I suppose it depends on the quality of the review,” he says, noting that CTRs can be seen as merely an exercise to be done, and may be overly risk averse.
“It comes back to moral leadership. You’ve got to have someone who is challenging the system. If you have people undertaking the reviews who don’t fundamentally believe in the philosophical principle of freedom, then they are not going to work.”
So how then do we really transform care? “There needs to be moral leadership from government, and appropriate funding in the right places,” says Lamb. “Unless you have a minister who is clearly interested in the issue and is willing to give clear leadership to the system about the imperative of change, I don’t think the system will just change of its own accord.”
Cuts to social care funding are another barrier to improving people’s lives. “Social care is the preventive end of the spectrum and, if you cut that, then people fall into crisis.
“The problem is in this country is that the NHS is like a national religion. Rightly so – but the result is that governments of all political persuasions don’t give sufficient attention to social care.
“And the public doesn’t fully understand what social care means. It’s quite an old-fashioned term and it just doesn’t get political attention.”
Given his views, it is no surprise that Lamb is in favour of health and social care funding being increasingly merged.
He admits to many anxieties about how it will work but says that he “cannot resile from it” after over a decade arguing for such reforms, both before and after he was a minister.
Lamb is also a strong advocate for preventive services, an approach he has championed in the mental health sector. He chairs the South London and Maudsley NHS Foundation Trust, an organisation with a budget of more than half a billion pounds and 6,000 staff.
Someone very senior said ‘we are not commissioned to do that’. That is such a hopeless answer because we’ve got a whole wealth of expertise
The specialist mental health trust has worked with the third sector locally, opening Be Well hubs in churches, schools and football clubs, taking a preventive approach to what Lamb calls the “psychological fall-out” from the pandemic.
When he first arrived at the Maudsley in 2020, Lamb asked about preventive work and “someone very senior said ‘we are not commissioned to do that’.”
“I thought that is such a hopeless answer because we’ve got a whole wealth of understanding and expertise here and we should be interested in how we prevent ill health.”
He wants the same approach to apply equally to people with a learning disability or autism: “Let’s work with those families to avoid a deterioration of their circumstance. And now, with the current reforms to the NHS, it does give us an opportunity.”
Referring to the new partnerships of organisations that plan and deliver local health and care services, he says: “We are part of the integrated care system. We can help shape a different approach.”
He believes that support for teenagers and young people is the key to avoiding further mental health admissions. He describes stressed and tired families dealing with a crisis “on a Friday night” which can lead to a hospital admission “and then they get stuck there”.
He tells me about an impressive service in his home county of Norfolk called Starfish+ which will work with a young person to see them through a weekend crisis, thus preventing an admission.
Active post politics
It is services like this that have led to the Sir Norman Lamb Health and Wellbeing Fund, which he set up after he left politics. Based in Norfolk, this gives small grants to local voluntary organisations working with people with mental ill health, learning disability or autism.
“We don’t insist on them creating some new project. We support them with the work they are doing,” he says.
The fund works with a coalition of charities in Norfolk, which has led to closer working between organisations. Lamb says the model could easily be spread across the country.
It is three years since he stood down as an MP so I ask about achievements that he is proud of. He demanded an investigation into Gosport Hospital, where a 2017 report found excess use of opiates. In more than 450 cases these had “hastened” death – or, as Lamb puts it, “they killed people”.
He led on new standards outlawing prone restraint in the NHS and reducing the use of restraint generally. He was instrumental in setting up Think Ahead, a national organisation that fast-tracks graduates into mental health social work.
Lamb is also proud of establishing access standards for early intervention in psychosis, within two weeks of an episode. There is evidence that early intervention can often stop the psychosis.
Yet, for all his ministerial achievements, he has sometimes been criticised for focusing on individual cases. Lamb invited all the families involved with Winterbourne View to meet him, for example.
He is also proud of his advocacy, furthering people’s causes in relation to mental health, learning disability and autism: “I went out there and made the case for them.”
Lamb says he felt it quite appropriate to challenge local authorities and clinical commissioning groups if they dragged their feet on discharge plans.
Ultimately, he says, it was this focus on individual people and their families that “made you understand the issues completely and understand the institutional barriers to change.”