HC Deb 11 April 1968 vol 762 cc1631-45

1.50 p.m.

Mr. Eric Moonman (Billericay)

Newspapers and television have in recent months highlighted disturbing accounts of the mentally ill arising from three sources: first, the condition of patients in Shelton Hospital, where a fire caused the death of 24 patients; second, The Guardian inquiry into Harperbury—described as a … mental hospital on a bad day … and, third, the kind of staff-patient relations described in "Sans Everything". I suggest that the area central to mental health has been overlooked, and that is the after care of the mentally sick.

I make two propositions, with which I am sure my hon. Friend the Parliamentary Secretary will agree. The first is that not all mental patients can be adequately treated in hospital; that the patient is likely to return to society if help, support and encouragement are there. The second is that the country cannot afford not to improve its after-care facilities, because, when a patient returns to work he is helping to cut down the incredible figure, in terms of working days lost through mental disorder, depression and nervousness, of £21 million a year from the National Insurance Fund. We ought to note, too, that it represents a loss of about 32 million working days annually.

The scale and cost of the treatment of mentally sick patients has tended to minimise the vital nature of after-care services, but the help given to a patient after a spell in hospital is merely an extension of the care required until he or she is reasonably fit and well again. The fact that one in nine women and one in 14 men in the United Kingdom will spend part of their lives in a mental hospital is a critical matter for after-care. The fact that 5,000 people commit suicide each year, but that 40,000 make the attempt, is also a critical matter for after-care.

When one considers the state of the community's mental health it is especially interesting to observe the way in which Sections 25 and 29 of the Mental Health Act are interpreted—the Sections that deal with the compulsory admission of patients to mental hospitals. For example, the Parliamentary Information Unit on Mental Health has observed that this varies throughout the country and is a pretty good indicator of local attitudes and quality of community care and other services.

In the Liverpool hospital region, the compulsory admission rate is over 110 per 100,000 of the population, compared with, say, Oxford, with about 50 per 100,000 of the population. These figures do not by any means represent the full extent of admissions, since most patients are admitted to mental hospitals on an informal basis, but they do represent a consequence of certain social conditions. They represent a problem of acute mental illness invariably in young adults and geriatric patients who are often the victims of both physical and mental disorder. The distress to the patient and to the relatives cannot be recorded in mere figures, so that it requires effort to examine the underlying significance.

Studies are constantly adding irrefutable evidence that better community care could reduce the numbers admitted to hospital, but I should like particularly to focus attention on these areas that need priority and urgent attention, and the need to define them. There is increasing evidence of severe mental disorder and stress illness in twilight areas where poverty and high density living are common factors. There is no doubt that overcrowding, unemployment, social classes IV and V—that is, the unskilled workers—are factors present in a preponderance of psychotic illness, but my point is that whilst many excellent and lengthy academic studies are being conducted, these areas need immediate help.

The collection of information on mortality seems to be a general exercise of local authority and Government statisticians, but if we are to provide efficient and effective services we must have information on morbidity. To be aware of suffering in retrospect is of limited value. We know that suicide, the only obvious mortality statistic for mental illness, is 10.4 per 100,000, but what we do not know is the number in our midst suffering the torment of serious mental distress.

We do not even know the numbers of mentally ill discharged into the area of each local authority whose responsibility it is to provide community care. All we seem to know is that 174,304 mentally disordered persons were under local authority care or supervision in 1966. This figure by no means represents the true numbers discharged from hospital and needing community care. It has been brought to my attention on more than one occasion that consultant psychiatrists ask, "What is the point of referring patients for community care When it does not exist?"

We must be careful, as we examine this very serious problem, that we do not unfairly criticise local authority progress, because a few authorities are glowing examples of what can be done. Yet a glance at the local authority plans for the rest of the country is enough to show the nonchalance that has infected the welfare plan. In other areas, it is near to despair.

An official report on the state of the public health states: Whilst the ill effect of poor environment and overcrowding may appear to be diminishing, and standards of education are improving, important differences (in health) may still be found in different areas. It is no surprise to me, therefore, to learn in a recent paper published by the Psychiatric Rehabilitation Association that certain areas of East and North London reveal an incidence of mental ill health much in excess of the national average. Information coming to the Parliamentary Information Unit on Mental Health also confirms the findings that this is a factor in the "East Ends" of other cities, such as Liverpool, Manchester, Leeds and Birmingham.

What does surprise me, however, and it is a point that received some emphasis in the recent "Man Alive" programme on B.B.C.2, is that the more deprived the area the higher the incidence of mental ill health and the smaller the resources for community care. I am not, of course, suggesting that mental illness is the exclusive misfortune of the deprived. It is well known that all social groups are vulnerable. If my memory serves me aright, even a king was so afflicted—so I suppose that, statistically, the rate amongst kings is very high.

But the number at present in our midst requiring urgent help is certainly far higher among those with negligible resources. There is an increasing belief that those who can afford it, or who can express their needs, will get a vastly better service than those who cannot. If there is doubt about this, a comparison of, say, Shelton Hospital with The Priory, Roehampton, or of a private appointment with some local out-patient clinic, will clarify the point.

Let us face the fact that the history of psychiatry in this country shows that certain hospitals are excellent examples of achievement, but some are disturbingly inefficient. This is clearly the result of leadership, or the lack of it. I am of the opinion that whilst our hospitals suffer from some material shortcomings, a recent report is right to imply that many of the difficulties encountered are due to inter-personal relationships and an almost paranoid resistance to progress.

In this event there seems a need for inspections of psychiatric hospital services. Not only is there a need for such inspection, but there is also a need that it should be done by an independent body—not just as part of the Ministry of Health because this would present difficulties of self-criticism. On the psychiatric services there is a need for a clear, determined policy to be reinforced by legislation if necessary. But, having treated—

The Parliamentary Secretary to the Ministry of Health (Mr. Julian Snow)

Is my hon. Friend suggesting that there is a lack of objectivity in connection with the administration of the National Health Service and the responsibilities of my right hon. Friend?

Mr. Moonman

I put it this way and relate this to a very considerable experience in business organisation and the like. If I wanted a fairly effective report on the state of an organisation in which I was concerned and of its working, I would certainly make inquiries in the organisation, but I would want further stimulation by inquiries made outside. This is the value of the rôle of the external advice which can be given by consultants.

Having had treatment for the symptoms, and usually by staff having little or no contact with the community, the patient is returned to exactly the same conditions which invariably precipitated the illness. The situation is aggravated by the artificial division of responsibility between the hospital and the local authority. Most patients are discharged from hospital without consultation with or even notification to local authority staff, who now have the responsibility for their social adaptation. There is also the problem that some communities more than others find it difficult to accept abnormal or eccentric behaviour in their midst and thereby influence the rate of readmission.

We are told that the development of community care is affected by the shortage of social workers. I think it time that we examined the rôle of the social worker. Discussions with social workers suggest that they certainly are overburdened and frustrated by the lack of community facilities. The conventional casework approach to rehabilitation on the "one-to-one" basis drastically limits the number of patients who can be helped. Therefore, there must be thousands who receive no help at all. The fact that the psychiatric patient does not cry out for help is not due to the lack of a problem, but to the nature of the illness or to the effects of drugs which silence the symptoms. Community care must take on a positive rôle, not merely maintain this silence, and enable the patient to fulfil a useful function in his society.

This can be done and it requires a more imaginative approach to the problem. At present what exists of community care is to a great extent a method of containing the mentally injured in the community without the community being aware. Community care should mean what it says—helping the community to care, you and I. To be meaningful it should be done by the individual, not left to a small group of professionals who often have limited awareness of the social milieu of the patient. This is not due to lack of concern but to the cultural distance of the professional. It is not surprising, therefore, that the selection of patients for case work is to some extent influenced by the cultural relationship of patient and therapist.

I draw attention to this, because in East and North London professional workers in the psychiatric field have learned that important lesson of harnessing the good will of lay people and training them to fulfil a useful rôle. They may not have the delicate refinements of those with an academic background but they contribute effectively to rehabilitation, using innate cultural knowledge, intelligence and compassion from the community itself. This makes sense of the professional worker's time, and he then acts as a catalyst and consultant. This is not a fantasy but already a fact. This is a community caring, but concepts such as this are anathema to the many reactionary areas throughout Britain which are resistant to progress.

Nevertheless, what is painfully apparent is that the areas with a high incidence of hospital admissions are invariably the areas where there is a legacy of substandard housing, overcrowding, high-density living, inferior education opportunities, few pupils staying on for further education, large numbers of children taken into care, large numbers of working days lost through illness, and so on. While we are calculating the significance of these facts we must immediately bring aid to them or at least ameliorate the consequences.

I suggest three areas which my hon. Friend might care to consider. First, there is an urgent reappraisal of our mental hospitals, secondly, an integrated imaginative community care programme, and thirdly, drastic improvements in the twilight areas. In these areas of mental health we perhaps often take for granted the enormous work done by organisations of a voluntary character as well as by the staff of the Ministry itself. I single out two organisations only because in the last two months they have been of particular help to the Parliamentary mental health movement, the Psychiatric Rehabilitation Association and the Mental Health Trust, which have been considerably stimulated in their approach in the last 18 months.

Mental illness, while having certain genetic features, is certainly aggravated or precipitated by environmental factors. Drugs, or at worst leucotomy, are no real solution to adjustment to adverse conditions. Neither is it a solution to change the name of National Assistance to that of Ministry of Social Security. Security is our environment, our homes, our work, our relationships, not just pension books. The co-ordination of the Ministry of Health and the Ministry of Social Security is a step in the right direction, although it is largely concerned with ill health. Real health is more closely linked with education, housing and employment and the health of twilight areas is dependent on these.

I appeal to my right hon. Friend to assure us that he views the lack of impetus in this field as a matter which will receive his immediate attention and to give us details of plans for the immediate future. We must remind ourselves that for every difference in the way men are treated a reason should be given and reasons which are relevant and socially operative.

2.6 p.m.

Mr. Paul Dean (Somerset, North)

The House is grateful to the hon. Member for Billericay (Mr. Moonman) for raising this extremely important subject before we rise for the Easter Recess. His speech has shown what we all know to be a very deep knowledge and concern for this problem. I thought when he was speaking of the work that is going on, for example, by the Psychiatric Rehabilitation Association and the valuable study it has made of this problem in the East of London.

That brings out very clearly the point he made about the problem being to some extent concentrated in the twilight areas, those areas which, by their very nature, with the resources available to them, find it more diffcult even to deal with the general level of mental illness whereas they often find that it is concentrated in them. What is the cause and the effect I do not believe we know, but we know that there are special problems in areas which are least able to deal with them.

I think one can see here in the whole field of mental illness and mental health a bright side in that the enormous advances which have taken place in medical science with new drugs and the like in recent years have made possible a cure, or at any rate an alleviation, of symptoms which not very long ago were regarded as virtually incurable and the days of the padded cell and that kind of thing, thank goodness, have been removed as a result.

There is also the unhappy side. As life becomes more complex and we all rush hither and thither, the incidence of mental illness tends to increase, and it looks as if it will go on doing so. Not only is this true. of the number of people who, during their lifetime, suffer from mental illness, but unhappily, of the number of readmissions. Something like 50 per cent. of those who enter hospital for treatment will find themselves back there sooner or later. This is the bleak side of the picture.

Perhaps the key answer to the points the hon. Member made about the need to improve the community care services is to get a better understanding among all those concerned. I think particularly of the three branches of the National Health Service. We need a better understanding among the family doctor, the hospital, the local authority and the voluntary bodies responsible for the after-care service.

The Report of the Royal Commission on Medical Education—Cmnd. 3569—gives some valuable pointers for the future. I am glad that it contains what is now generally accepted as obvious but what is quite revolutionary in medical education, namely, the emphasis on the need for training doctors in psychiatry. Paragraph 263 of the Report, dealing with undergraduate medical courses, contains this sentence: We have repeatedly emphasised that the object of the undergraduate medical course is education and not vocational training; any doctor who remains ignorant of human psychology (both normal and abnormal) must be considered ill-educated, however thoroughly he may be trained in his chosen specialty, because this subject permeates the whole of medical practice. When this is fully incorporated, as I hope it will be, into medical training, we shall have gone some way towards getting a community of understanding between the various branches of the service, which still tend to some extent to work in isolation and not fully to understand each other's problems.

The more cash and care problems that can be seen as one whole, the better. It is therefore very welcome that the Lord President of the Council will have a broad supervisory rôle over the cash Ministry—the Ministry of Social Security—the care Ministry—the Ministry of Health—and, I trust, the rehabilitation services of the Ministry of Labour, as well as some of the functions now performed by the Home Office, so that there can at least be at the centre a coordinating voice who can try to ensure that all the various aspects of what is, for the individual concerned, one problem are considered as a whole and the various forces brought to bear in the best possible way.

This is a very wide problem. It is much wider than simply psychiatric social workers in the local authority sphere or the work which voluntary bodies do. It extends to all the factors and all the aspects which make human life worth living and which make for a full and complete life. The obvious and tragic point is that so often someone who has suffered mental illness has no family when he comes out. There is, therefore, the immediate need for friendly neighbourly support which will act in some measure as a substitute for the family unit. This leads directly to the need for hostels and short-stay accommodation in the early stages after people have come out of hospital.

The need for training is another fundamental to the successful cure and rehabilitation of someone who has suffered from mental illness. We have all met the problem time and time again of someone who has been into a mental home. who has probably been cured, or at any rate had his symptoms substantially alleviated, and who has left hospital full of hope for the future. He has probably gone to a training centre or to a rehabilitation centre and taken a course. He has left there, too, full of hope for the future. This is where the trouble often arises. Who is to employ him? Who will provide the sheltered environment which is essential if the cure started in hospital is to be completed? So often this is where the rub comes, the relapse takes place, and the dreary process goes on again.

The hon. Gentleman was absolutely right to put as the essential feature of the success of the process of the cure of mental illness the supporting services which are available in the community. I know that the Parliamentary Secretary will say, quite fairly, that there has been progress over recent years. I expect he will quote figures of the growing number of psychiatric social workers and the like. I believe he realises, however, that however good mental hospitals may be, unless the supporting services in the community are right, much of the money put into mental hospitals Will—be wasted. It is not only the economic factor—the waste of money—but also the social waste. We have met people who have come out of mental hospitals full of hope and who have then found that the pressures of life are weighted against them. All the good work is dispersed for want of these key services in the community.

I therefore hope that, whatever else the Parliamentary Secretary says, he will recognise that in these days, and indeed at any time when priorities have to be allocated, there should be no higher priority in the treatment of mental illness than the supporting services in the community.

2.16 p.m.

The Parliamentary Secretary to the Ministry of Health (Mr. Julian Snow)

I am obliged to the hon. Member for Somerset, North (Mr. Dean) for drawing the attention of the House to the passage in the Report of the Royal Commission on Medical Education which concerns medical training in problems of mental health. This is a very important matter, because to that list of possible changes in medical education could be added a number of matters which deserve more emphasis in the light of modern conditions. For instance, the general provisions of public health are sometimes not entirely well comprehended by the mass of the medical profession.

The House is indebted to my hon. Friend the Member for Billericay (Mr. Moonman) for raising the question of mental after-care services. I take his point that it appears as though mental ill-health is a poverty disease and that the exact association of the two factors has never been properly resolved. Many years ago I assisted in a voluntary organisation for psychiatric social services. I am well aware that the type of patient we had to cope with invariably came from a background of poverty.

I am probably mistaken, but I formed the impression that my hon. Friend had not fully comprehended the Health Services and Public Health Bill, which has now received its Third Reading. Clause 12 of the Bill covers many of the permissive powers, and sometimes obligatory powers, imposed on local health authorities. The Clause will repay very close study. It could be the foundation of the propaganda to educate the public which is so very necessary.

Half the trouble in dealing with unofficial bodies whose aim is to improve the service and the provision of care or of after-care for mental patients is that so many of the organisations have people behind them who are extremely enthusiastic, who fulfil extremely good jobs, but many of whom are furthering particular forms of psychiatry or mental health reorganisation. Most of these rivalries start from the early days of social psychiatry work and investigation and social psychiatry itself. The position is further complicated by the fact that when adopted or adapted by British organisations these rival schools, many of which were foreign—they are none the worse for that—develop forms of ideas and theories which tend to be slightly confused. This is in the nature of things and, probably, the flexibility which it creates is not only inevitable but in some ways desirable in order that new ideas may be brought forward, studied and put into operation.

The attitude of the public towards the mentally ill has become much more tolerant and understanding in the past few years, but there is still a great deal of ignorance about mental illness, about the services provided for the mentally ill and about the ways in which the community can help the mentally ill and their families. Suspicion and prejudice are beginning to disappear, but some remains. I am sure that public discussion on the problems of mental illness and the means of helping those who are afflicted by it can make a valuable contribution towards better understanding and progressive thinking about the future of the psychiatric services.

Better attitudes on the part of the general public, a greater appreciation of the problems which mental illness presents and an approach which is not merely sympathetic but also constructive towards those who have been through some form of psychiatric illness can in themselves do much to further the after-care of such patients. So often, there are situations in which the attitude and insight of, for example, employers, landlords, housing managers and members of local authorities—to mention but a few—can make the difference between relative success and failure in the process of rehabilitation.

One matter about which we ought to think very carefully is the large and growing section of the population who live in "bed-sitters". The conditions of life for people who live in bed-sitters—this is not peculiar to London alone—and the whole atmosphere of loneliness and stress are conducive to the development of mental problems. Anything that this debate can do to spread a healthy and positive approach to the problems of the mentally ill will be well worth while.

Mental health is a wide-ranging subject, and my hon. Friend has restricted himself largely to the question of aftercare. The first matter we should remember when considering after-care services for the mentally ill is that the whole pattern of hospital treatment has changed radically in recent years. Many patients can now be treated as out-patients or in day hospitals. Hon. Members will know of the extremely good work being done by the Marlborough day hospital in London.

People admitted to hospital usually need only a short period of treatment as in-patients, though sometimes this may mean admission on two or three occasions before the medical position has become stabilised. Now that patients spend much less time in hospital, the whole balance of the service has changed and far greater provision is now needed for the mentally ill outside hospital who need to be helped towards normal life. Their families, too, need support. This calls for the closest co-operation between the three parts of this service. I take the point made by the hon. Member for Somerset, North about the need for greater co-ordination. A close examination of what is implied in this connection by the Green Paper mentioned earlier this Session by my right hon. Friend may well have a marked effect.

We aim to build up a fully comprehensive psychiatric service providing all the facilities needed, from early diagnosis to rehabilitation and restoration to normal living. It must be designed to meet the needs and circumstances of the area concerned and be capable of adjustment and change as experience dictates. In the day-to-day provision of services to meet individual needs, a wide range of social services often has to be brought in, including the home help service, the services of the Ministry of Labour disablement resettlement officers, sheltered workshops, industrial therapy organisations, industrial rehabilitation units, the services of the Ministry of Social Security, the provision of housing, and the services of the children's department of the local authority. All these services must be brought together to make a unified provision.

In general, it is the mental health social worker who has the key part to play. He may be employed by the hospital or by the local health authority, or he may have a joint appointment. Practice varies. But, whatever the form adopted, the basic aim should be the same. The social worker should be fully aware of all the circumstances of his clients and should be able to use his professional expertise and knowledge of the statutory and voluntary services in order to put his client, or his family, in touch with the service which can best help them. One of the difficulties which I have found as a Member of Parliament—I have no doubt that others have found the same—is that it is assumed that people know where to go and whom to ask. But this is not so. As a Member of Parliament, one often has to find out what services can help and how one should go about things in order to help people who are not able to help themselves in these matters.

Unfortunately, there is a shortage of social workers, though I am glad to say that the position has improved. At the end of 1961, the local authorities employed about 1,100 mental health social workers. By September, 1967, the figure was about 1,350. In other words, the force had increased by about 23 per cent. But, despite this increase, the number of unfilled vacancies has been almost doubled in that period, and this situation will probably continue for some time yet. There is nothing new in this. As one level of need is met, more needy cases tend to come to the surface.

Another important element of the local health authority services for the mentally ill is the provision of residential accommodation. Social circumstances and environment, as I said earlier when speaking about the "bed-sitter" population, can be contributory causes of certain forms of mental disorder. Therefore, in some cases, removal from home, or what is called home sometimes, to a more satisfactory environment can prevent a com- plete breakdown. In other cases, a short period in a hostel after in-patient treatment can make a useful contribution to rehabilitation.

The change from hospital to ordinary outside life is probably so severe in some cases that a staging process ought to be introduced, and in many places it is already in operation. It may be that the discharged patient will need a degree of support for a longer period, and this need can be met in several ways. One useful development is that some hospitals provide pre-discharge hostels away from the main psychiatric buildings themselves. Some local authorities provide hostels. At the end of 1966, there were 80 such hostels with about 1,500 places. Boarding out in a private household may sometimes be an alternative answer to the problem.

In recent years, there have been several interesting experiments in which small groups have lived together with a minimum of supervision. More recently still, some authorities have experimented with bed-sitting rooms and small flatlets where the resident is quite independent, apart from the support and advice of the social work staff. Here, I distinguish between the purely commercial form of "bedsitters" and those bed-sitting rooms or single rooms provided with adequate attendance to ensure that the interests of the people in the building are catered for. Not all the hostels provided have been used as intensively as was at first expected. No doubt, there are many factors at work here. But not the least important may be the changing pattern of in-patient treatment to which I referred.

If I had more time, I should give more attention to what is at present being done. A great deal has been done in the provision of industrial training, under supervision, with a view not only to rehabilitation but to enabling patients actually to get back to normal conditions of outside work. There has been good progress here, giving very satisfactory results in many cases.

Recently, the Ministry of Labour established an agency industrial rehabilitation unit. Other areas are looking at this sort of arrangement. In addition, more psychiatric hospitals have now established day hospitals which offer a range of services, including occupational thereapy and some industrial activity. The number of attendances at these day hospitals has risen dramatically, from less than:300,000 in 1961 to over 1 million in 1966—though not all these are psychiatric cases.

It is important in the context of this debate to understand the problems which appear to be peculiar to south-east London. There is a large area here where patients with varying degrees of mental ill health have to be catered for. The co-ordination which my hon. Friend stressed is essential. Research on this is being carried out by the Medical Research Council and my Department. At Chichester there is a Medical Research Council unit which has been studying the effect of different hospital admission policies, and we are also doing this sort of research elsewhere.

My hon. Friend has suggested that we should establish a programme of priority areas. The Department at present has no power to provide this sort of grant in aid of local authority health services, which include their mental health services. Nevertheless, some help is being given through the rate support grant as a direct grant from the Exchequer.

This is a very long and difficult subject to cover. I think that although my reply has been rather hurried I have indicated to my hon. Friend that we understand the problem of the areas with particular problems I hope that he will accept Clause 12 of the Bill to which I have referred as evidence of the sort of thinking we are undertaking now in order to provide local authorities with greater powers for after-care.