§ 2.45 p.m.
§ Mr. Cecil Parkinson (Hertfordshire, South)
First, through you, Mr. Deputy Speaker, may I thank Mr. Speaker for giving me the privilege of a debate on this important subject on the last-day before the Easter Recess. I have no ambition to deal in an acrimonious way with any aspect of Government policy. I hope to discuss with the House some of the problems of mental hospitals and patients and staff in those hospitals.
In my constituency there are five major mental hospitals, with over 6,500 beds. Many people were slightly alarmed by a sentence in the recent speech of the Secretary of State to the National Society for Mental Health in which she said "Most hospitals have now achieved the 755 greater part of the minimum standards set in 1969"
If we allow her claim, I do not think that anybody would accuse the Secretary of State of claiming a great deal. The greater part of the minimum standards were set six years ago. The fact that they have been almost achieved is an achievement of a kind, but it is nothing to boast about. The Secretary of State was not boasting about it.
However, many of my constituents do not accept even that limited claim. They are extremely concerned that the minimum standards which we might have expected six years ago, after a policy had been embarked upon by successive Governments, are nowhere near to being maintained and only appear to be maintained by the use of slightly dubious statistical measures.
Let us take the case of a hospital with an average of 60 patients in its wards. We can upgrade half of the wards so that there are 40 patients in them. We can divide by two and claim that the ward occupation level has fallen by an average of 10. That is true. However, half of the hospital lives at an acceptable level at that point while the other half lives at a totally unacceptable level. But if we calculate the average, the figures can be made to look reasonable.
Since I have been the Member of Parliament for Hertfordshire, South I have become concerned at the state of the hospitals in my constituency. I am not making a specifically constituency speech since an area containing hospitals which serve most of North London and a large part of Hertfordshire does not attract purely local interest. However, I suggest that this teaches us lessons which may be of general application. The five hospitals concerned—Napsbury, Shenley, Hill End, Cell Barnes and Harperbury—treat the whole range of handicaps and problems of the subnormal.
Recently I read an interesting paper by Dr. R. D. Scott, who is consultant psychiatrist at the Napsbury Hospital. He is passionately devoted to supporting the Government's policy of running down the big hospitals and building up community care facilities. In his paper Dr. Scott sets out his arguments for the need for a research unit to look into the question of the treatment of the handicapped and how the Ministry's 756 policy, which has been followed by successive Governments of both parties, is working out.
I should like to quote one or two of the more significant sentences contained in this important paper. On page 1 Dr. Scott says:there is a singular lack of reliable signposts to the best pathways for the rehabilitation of different types of patients in the community.In other words, we all accept that we must build up the treatment of patients in the community, but there is an appalling and abysmal lack of knowledge of the sort of facilities which the community needs to do just that.
Dr. Scott goes on to say:There is no real knowledge of just what sort of facilities are needed—just demands for more facilities.Another telling sentence reads:There is a need for research and monitoring to discover what are the best facilities.Then come what are perhaps the most interesting sentences in the paper:There are very limited comparable studies comparing the functioning of a community-based hospital service with traditional hospital-based treatments. It is surprising, in view of the revolutionary nature of the Department's policies, that virtually nothing in the way of comparative evaluation has been attempted.Some years ago this country embarked upon a revolutionary approach to the treatment of the mentally ill. The decision was taken that the large custodial hospitals should be run down and reduced in size and that more and more patients should be treated in the community and that a range of facilities should be built up in the community so that the mentally ill and mentally handicapped should not be siphoned away, put out to grass in Hertfordshire just north of London and forgotten. It was decided that they should be retained in the community and treated there and not be cut off from it.
The idea behind that is obvious. It would prevent such people from being institutionalised. At a time when a person was mentally ill, instead of being taken away from everyone he knew and the surroundings which he knew, he would be kept in contact with his family and his community and treated in a small sector hospital. He would not be extracted from the community but would continue to live in it. Therefore, instead of taking people from the community and then having to 757 find ways of reintroducing them gradually, the idea was to retain them in the community and to treat them there. It was thought that in that way a major step forward would be taken.
I support that approach wholeheartedly. The theory is unobjectionable. But the way that the policy has developed in practice is quite different.
Rather than talk in general terms, perhaps I may give illustrations from some of the hospitals in my constituency. I take first the Harperbury Hospital at Radlett, which is a subnormality hospital with 1,276 beds. The medical staff support the Department's policies and have done their best to implement them. They started by getting permission and funds from Governments of both parties to upgrade their wards. Instead of having appalling overcrowding, with 60-odd people being crammed into a ward where it was possible only to hold and to look after people and not possible to treat them in any way, a process of upgrading was begun.
Every time that a ward is upgraded, however, instead of having 62 patients, the end result is that only 40 go back into better surroundings. There is less overcrowding, the surroundings are improved, and the nurses can start to treat their patients and see improvements.
It might be assumed that if the Department's policy is that 22 beds shall disappear, 22 more places will be found somewhere else. But this has not happened. All that has happened is that Harperbury Hospital has been forced to improvise, with the result that 50 patients now sleep in a hospital which is due to be closed because there is nowhere else for them to go. By the time that Harper-bury has finished its upgrading process, 197 patients will have nowhere to sleep.
The hospitals are playing their part. They are becoming better places in which to treat the mentally ill. With the fall in the number of hospital beds, however, places are not being developed in the community. All that is happening is that a hospital like Harperbury is slowly strangling itself. It cannot look after its patients. There are not sufficient beds, and it is boarding out many patients in places where it can find beds.
758 At the end of the day the community services are not developing. The hospital services are improving. But the Government are blithely following a policy which assumes that one facility will run down at the rate that the other develops. That is not happening. The result is that the staff at Harperbury find themselves in a vice. They are improving facilities, they are carrying out the Department's policy, but the community services are not developing.
Dr. Scott has suggested that one reason why community services are not developing is that we do not know what facilities should be developed. No research has been done. When in doubt, people tend to ask for yet another hostel. But Dr. Scott's research has shown that 16 people who went into hostels took a step back. They did not continue to improve but got worse.
We have a policy which sounds quite unobjectionable. However, although the hospitals are being run down, the community facilities are not developing. Yet the Ministry pursues its policy on the assumption that community facilities will develop.
What is happening again in Harper-bury is that in the children's section, two-thirds of the 200 beds set aside for children are occupied by adults. There is no possibility of transferring people when they grow up from the children's section to the adults' section, because the beds in the adults' section are run down and over-subscribed already.
Dr. Ricks, who is one of our leading authorities on the treatment of children, is in the frustrating situation of having two-thirds of his beds occupied by adults for whom there is no place elsewhere, knowing that in the community there are many children who need his facilities and who could be treated if he could accept them. But he is not allowed to have more space and to build more facilities. The hospital is not allowed to build more space to take the adults who at present occupy children's beds.
If one tries to take account of the cost of the support facilities to keep in the community children who should be in the hospital—I refer to the social worker, the welfare worker, the doctor, the nurses and all the other support systems which have to be extended to try to help a 759 family with a severely disturbed child living in the family—one comes to the conclusion that it is very expensive to deny people like Dr. Ricks the facilities to treat children in hospitals because the Government's policy is not to build up the big hospitals any further.
I feel very strongly about this subject, and there are many other aspects of the lack of success which I could report. I could point to the fact that one of my hospitals will be ordered by magistrates to take a dangerous patient whom it is not in a position to look after. The medical committee has said that the hospital does not have the security facilities to look after the patient. The magistrates will order the doctors to accept the patient. The medical opinion of the doctors will be overruled.
There are in my constituency a substantial number of ex-Broadmoor patients who should be in secure hospitals but for whom there is no place in secure hospitals. The result is that the hospitals and the community have living in them patients whom the doctors know should not be there. There is nowhere else for them to go. This again gives the lie to the idea that the minimum standards required are being attained.
There is a chronic shortage of secure places for criminally disturbed patients, but it is news only when an unfortunate patient gets out of care and does something which damages or injures someone, and then the medical staff come under attack. At present the staff are in an impossible position. They are forced to treat people whom they know they are not geared to treat. I want to return to this subject on many occasions in future.
I have talked about only two of the hospitals concerned. Hill End Hospital is the victim of another aspect of the Government's policy which I suggest is not proving satisfactory. The Department has made a totally arbitrary decision that any hospital with fewer than 1,000 beds cannot be given psychiatric divisional status. That does not sound important, but a hospital without psychiatric divisional status is not allowed to have a divisional nursing officer as its head nurse. The chief nursing officer must be of a lower grade. Therefore, the career prospects for everybody in the hospital are reduced because the limit to their promotion opportunities is set lower.
760 The Department's policy is to run down the big hospitals and to build up community services. Hill End is a first-class hospital which has done just that. What is its reward? It has been told that, because it does not have 1,000 people in beds—the policy is to get people out into the community—the status of all the people who work there should be reduced. I suggest that the Department should look at that matter very seriously. If the policy is to get people out into the community and the result for nurses and medical staff who work hard to achieve that end is a lowering of status, the Department will not get the enthusiastic co—operation that it needs.
I have heard from the Department that this policy is being reviewed and that new criteria will be established. This must be done quickly. Good people are applying for other jobs because they feel that promotion prospects in this hospital are not as good as they were.
I believe that the Government's policy of running down the big hospitals and building up in the community as a long-term objective is right, but they must be more flexible in their approach. They must not pretend that their policy is working out when we know that it is not. Local authorities are not making plans to deal with the patients who will be discharged from mental and sub-normality hospitals. The hospitals are running down their beds and facilities at a rate which local authorities are not planning to take up by creating facilities within communities. Local authorities are not seized of the scale of facilities which they will be called upon to provide.
The Government must recognise this situation and, in places like Harperbury, make money available to ensure that extra facilities are available in hospitals so that the upgrading process can carry on. It is no use telling Harperbury to go on improving itself without making constructive suggestions about where the 200 bedless patients should go. The Department must be flexible and be prepared to make Crossman-type units available in hospitals like Harperbury as a temporary measure to take the strain.
I suggest that the Government should look again at the most interesting proposal that has been put to me by the 761 medical committee at Harperbury for turning some of the big hospitals into village communities. There is growing doubt both on this side of the Atlantic and in America, where the policy was pioneered, whether the Government's policy is right.
We are finding at Harperbury that many people who are discharged do not feel at home in the community. Their community is not our community. Some feel at home in the community, and by all means let us get those people back into the community.
Harperbury has plenty of ground available, so why not set out to transform it into a village community? Some patients there want to get married. They are capable of being self-sustaining. However, they do not rank on any local authority housing list. There are acres of grounds at the hospital which belong to the Department for which planning permission could be obtained and on which buildings could be erected. Harperbury could be transformed over a number of years into a community with sheltered accommodation—bungalows, hostels and houses—where people would not be cut off from the facilities they need.
I realise that it is asking a lot of the Minister to comment today, but I invite him to visit Harperbury to discuss the proposition and see just what can be done.
Let us not say that these big hospitals must go but let us consider whether we can transform them. The facilities are not being made available in the community. However, perhaps we can use what is available to produce a new type of community. Let us get rid of the old custodial hospitals but transform some of them into village communities.
There is a chronic shortage of facilities for treating children. There is nowhere for children to go when they become adults. The adult sections of the hospitals are already full. Children in their formative years are being denied the opportunity which might give them a chance in life.
I have a great deal more to say, but I want to leave the Minister time to reply. The staff at these hospitals have had a glimpse of what they can do for their patients, given the proper facilities. They 762 know that people for whom life appeared hopeless can be helped to re-establish themselves in society. They are in the frustrating situation of knowing what they can do but of being denied the facilities to do it. I hope that the Secretary of State will not make any more speeches about minimum standards having nearly been attained. It simply is not true.
§ 3.8 p.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Alec Jones)
I am grateful to the hon. Member for Hertfordshire, South (Mr. Parkinson) for raising this important subject. The Government have promised a White Paper on mental illness. I am sure that the hon. Gentleman and I await that publication with interest.
Basically, there is a sharing of objectives at least between the Department, the hon. Gentleman and the doctors to whom he referred. There is an obvious desire on all sides to do more in this sphere. However, the hon. Gentleman knows as well as I do that the limiting factor is not lack of concern or desire but lack of finance. It is easy to say that the Government must make more money available. I have heard those words on many occasions. All the causes for which those words are used are good and worthy. However, we must accept that in our present financial position there are bound to be serious financial restraints on the things that we would otherwise like to do.
§ Mr. Parkinson
I accept the limitation on resources. But can we try to examine the situation to make sure that the available resources are applied in the best possible way?
§ Mr. Deputy Speaker (Mr. George Thomas)
I remind the House that Mr. Speaker set half an hour for this debate.
§ Mr. Jones
I shall hasten on my way, Mr. Speaker, and try to deal with some of the points made by the hon. Gentleman.
I start with the 1971 White Paper "Better Services for the Mentally Handicapped". I confirm that it is still the Government's policy that there should be a shift in the balance from hospital to community care with an expansion in local authority services and a relative 763 reduction in the numbers cared for in the hospital service.
The hon. Gentleman is concerned, and rightly so, that there is not a sufficient build-up in community services to permit a reduction in hospital beds, and he and I would wish to move a lot faster in the build-up of community services. Nevertheless it is right to put on record that in the local authority sector up until 1973 both revenue expenditure and the take-up of loan sanction for capital were broadly in line with the expenditure targets in the 1971 White Paper.
Local authorities in general have given high priority to developing services for the mentally handicapped, and in 1973–74 their bids for loan sanction capital were four times greater than the White Paper had provided for. It was the Government, with their overall economic responsibilities, who had to control social services capital expenditure, and initially mental handicap was not shielded from the December 1973 cuts.
However, when last autumn an additional£20 million was made available by the Government for capital expenditure on health and personal social services, we decided that mental handicap, among other things, should be given a special priority, and this year we shall almost be back to the target levels set in the 1971 White Paper, despite the December 1973 cuts.
Local authorities now have and are exercising much greater freedom to decide their own priorities, and the capital projects provisionally approved for next year indicate a continued increase in this field of about 3,500 places in adult training centres and 1,400 places in residential homes, about 250 of them being for children.
Bearing in mind that the bulk of mentally handicapped in residential care will continue to be in hospitals, we cannot neglect that sector, and, as the hon. Gentleman illustrated from his constituency, we have a commitment to improve—but not to extend—the existing large hospitals. This is accompanied by the development of a decentralised hospital service which will be able to link more closely with the local community services.
The hon. Gentleman suggested that we were juggling the figures. I accept the point that the space standards set down 764 were the minimum, but by December 1973 there were only eight hospitals in the country which did not satisfy those minimum standards, and since then the number has fallen. I use those figures not to try to say that everything in the garden is lovely but to show that there has been an improvement in the overcrowding situation, and there have been similar improvements in the nurse-patient ratio. In 1969 the nurse-patient ratio was 1 to 3.9. In 1974 –75 it had fallen to 1 to 2.5, again indicating an improvement of the kind which the hon. Gentleman is concerned to bring about.
The hon. Gentleman referred to the speech made by my right hon. Friend the Secretary of State. I do not want to repeat all the points my right hon. Friend made, but the first measure which she announced on that day—the establishment of a national development group for the mentally handicapped—is well advanced. The chairman of the group, Professor Mittler, has started work and it is hoped to announce the full membership of the group after Easter. It will lead us into advice and research of the kind which the hon. Gentleman requires.
I accept that an objective comparison of hospital and community care is desirable, and I am glad to tell the hon. Gentleman that two research studies are already being undertaken. One is in Wessex and is supported by the Department in conjunction with the Medical Research Council, and Southampton University is evaluating alternative forms of residential care. The other study, initiated by the Department in Sheffield, is a development study in co-ordinated planning of hospital and local authority community care in that defined area.
The hon. Gentleman referred to overcrowding, and I appreciate the point he made about Harperbury. The problem that we come up against is that if we ease overcrowding we automatically reduce the number of beds available, which leads to further problems of the kind mentioned by the hon. Gentleman. I share his wish to improve the overcrowding situation, and I am sure he will acknowledge that a great deal has been achieved in this respect in past years.
I noted with considerable concern the hon. Gentleman's remarks about the 765 setting up of children's beds. The population served by Harperbury is about one million, and on the basis of planning figures given in "Better Services for the Mentally Handicapped" about 130 children's beds are required. This is rather fewer than the 200 nominally provided at Harperbury, but I understand the difficulties there. At present it has only slightly more than 70 children under the age of 16. There is, therefore, a question of definition as to who or what is a child in these matters.
The North West Thames Regional Health Authority has plans to provide a number of small local hospitals in Harrow and Brent, and in the longer term in Ealing. These will bring needed overall relief and, I hope, enable Harperbury to return all its children's beds to that use.
The hon. Gentleman referred to secure accommodation. The Department is aware that a gap has developed between the high security provision of the special hospitals and provision in the ordinary hospitals where the staffing does not always permit of the degree of supervision and control that is needed in a small minority of cases. Last year my right hon. Friend asked regional health authorities to take urgent action to establish regional security units for such patients.
The hon. Gentleman referred to Hill End Hospital. My hon. Friend the Minister of State wrote to him on 24th January on this matter making the point that it would be wrong to continue basing divisional nursing officer status on the number of beds and saying that a review of the criteria was under way. We have made good progress with the review and, subject to the agreement of the staff associations to our proposals, we hope to make an announcement in the very near future. I trust that this will result in an improvement in the situation at Hill End.
The hon. Gentleman raised a number of other points. I shall write to him in reply because of the time factor today. I am grateful to him for raising the question of Harperbury in particular and for drawing attention to the general problem. It is not a question of complacency. My 766 right hon. Friend and I will not rest content until all the difficulties, not only at Harperbury but throughout the service, are removed.