§ 3.30 p.m.
§ Mr. Phillip Whitehead (Derby, North)
I am grateful to the right hon. and learned Member for Huntingdonshire (Sir D. Renton) for sitting down on time. I hope not to detain the House for too long.
The background to this debate concerns two prolonged and potentially tragic cases in my constituency which, together, it seems to me, illustrate the need for more psychiatric help and in-patient placement in Derbyshire hospitals. I hope to show that in the Trent area in Derbyshire in particular we are somewhat lacking in that respect, as my hon. Friend the Minister of State has acknowledged several times in correspondence to me.
Both these cases have been going on for years. I know the people well. I have come to know their families well and to respect them. I have in the past invited the assistance of the Department in this matter, thus far without success, 1459 and, as the story unfolds, the House will see that I have not been precipitate in bringing this matter forward for debate. We are talking not of weeks or months but of years of correspondence and pressure in both cases.
For reasons which the House will understand, I do not propose to refer to the two people by name. The young lady has been referred to as Miss X in the Derbyshire papers from time to time, although her real name has also been used locally because she has frequently been before the courts. The young man to whom I shall be referring has not been before the courts in this connection, and I propose to refer to him as Mr. Y. It helps that they are of different sexes and can be so discussed.
The history of the first case is that since the age of 13 this young lady has suffered from a variety of disorders of personality. She was for a period of time put into the local authority hostel for the mentally ill. There have been various attempts to rehabilitate her and to provide employment for her, and she has had a prolonged stay in the Pastures hospital at Derby when her personality disorder was first diagnosed. In 1974 she was transferred to the Francis Dixon unit of the Towers psychiatric hospital at Leicester. She was there for eight months taking part in group therapy treatment, but that was not successful and she was discharged in October 1974.
It is with the events from October 1974 to the present time that I wish to deal, because in this period of time she has on several occasions been before the courts. She has been in and out of mental hospitals in Derby and the Derby area, and the case, I submit, is one which is now on the brink of potential tragedy.
This case came to my notice when the girl's father and a local councillor called a Press conference at the offices of the county council in August of last year to describe the case and the efforts that had been made to get some kind of proper in-patient treatment for her. Since then we have been in what seems to me a spiral not of inactivity but of inability to see that only lasting care for this young lady—and others with her condition—can redeem her and bring her back to a useful life within the community and also help her unfortunate family, which has borne 1460 the strain of coping with many of these disorders for some time.
The first thing that has happened in the case of this young lady is that as a result of being discharged from hospital and sent first to her own home and then to the home of an uncle and aunt who had offered to take care of her, she, after a series of disturbances, committed some trivial offence—I tnink it was breaking a window—as a result of which she was brought before the magistrates' court. The court remanded her to Risley Remand Centre for medical reports. I went to Risley to see her there and made her acquaintance for the first time. The reports were brought to the court, and simultaneously I approached the Department to see whether it was possible—we are talking of events almost 10 months ago—to get proper in-patient help for her in a hospital, though not necessarily in Derbyshire. It seems to me that there should be some back-up, machinery, and if that could not be done there ought to be co-ordination and effort masterminded by the Department.
Unfortunately, that is not what has happened. The report that was submitted to the court by the medical officer at Risley Remand Centre—going back to the time that I saw her—said that she was—as indeed, she is—of "good average intelligence" and that she did not suffer from any serious mental illness. The report continued:She suffers from a disorder of personality which could be dealt with under the Mental Health Act and she has had this disability since the age of four and there is a possibility that it might be susceptible to training but it would have to be in a rigid structured environment.On the basis of that and my own estimate of the case, and the inability of both the social services in Derbyshire and the hospital authorities in Derby to cope with this case—in that each was passing it to the other and saying "We shall see what we can do but this is not wholly our responsibility"—I wrote to the Department of Health and Social Security. After some consideration of the case, the Department turned down the request for assistance from outside the area. The medical authorities at Risley were informed on 5th September 1975:We have carefully considered your letter of 28th August and the accompanying reports but can find no evidence that any treatment 1461 which she may need could not be carried out in a degree of security less than is provided by the special hospitals. We suggest therefore if it is thought that she would be helped by psychiatric treatment the assistance of the Regional Health Authority be sought in obtaining a suitable place.The letter went on to say that the Mental Health Act could not be used because she was diagnosed as suffering only from psychopathic disorder.
The difficulty with all that is that Miss X came back into the court, and ultimately came up before the crown court in Derby. We must bear in mind that by this time she had been in Risley for a considerable period. I mean no disrespect to the authorities at Risley, but it is not a particularly nice place in which to be. It is essentially a remand centre for alleged offenders. It is not for people who have a mental disorder of one kind or another.
Ultimately, the Area Health Administrator told me at the end of September that this girl could be admitted to the Kingsway Hospital in Derby and that she had been told that it was in her interests to remain there under psychiatric care and treatment until she appeared in the crown court for sentence. As a result of that, her sentence at the crown court was, essentially, that the case was dismissed and the court wished her well in that hospital.
However, I regret to say that after she was moved back to the Kingsway Hospital the sequence of events began to repeat itself. What we had then was a decision of the hospital that it could not cope with her as an inpatient after a period, and it was decided to move her to day care and to send her home.
She went home on 14th February. I visited her parents on the night before she came home on 14th February. Their younger daughter, who is preparing for her A-levels, was leaving home. She was walking out. She could not bear it. She was in a state of great distress. The parents were also very distressed. I persuaded them—I thought it right to do so—that they should at least attempt to go along with what was proposed and that the girl should go to day care at the Kingsway Hospital but for the rest of the time she should be at home.
That situation has not been stable. On 12th March a meeting of the social services authorities and the area health 1462 authority in Derby was held. As a result of this, no agreement could be reached about precisely who was responsible for additional back-up services. The social services department said that it greatly regretted the situation but that there was nothing that it could do, and that the girl was the patient of a particular specialist at the hospital. The hospital said that it hoped that the situation would stabilise and that she would remain as a day patient.
I have, indeed, had letters from people who have been responsible for her treatment at the Thornhill Day Hospital, which is attached to Kingsway Hospital, to say that they think they were making progress with her and that she was responding to treatment and therapy. That is what I would expect. This girl is intelligent and potentially she is a warm human being and someone who could be valuably reintegrated into society. But this would take a great deal of time. There is all the scar tissue of the last nine years somehow to be replaced. That will take a lot of time and it cannot be done in the present unstable situation.
To bring the story right up to date, Miss X has now been locked out from home. Her parents found that they could not take her any longer. The domestic situation was utterly intolerable, and therefore she was locked out. She created a mild disturbance at the hospital. In fact, she threw a typewriter on the floor. I do not think that she even damaged it. However, as a result, she was sent back first to the magistrates' court and then to Risley.
She has been remanded from the magistrates' court until she can appear again in the crown court in four weeks' time. This cyclical pattern is repeating itself. It cannot do any good for her and it is doing no good to her family. It does not cast a very good light on the response that I have had thus far from the authorities, over and above the immediate specialists and social workers who have genuinely tried to help and care for this girl in the interim period.
The position is that there is now some disagreement even between the authorities on how the case ought to be dealt with. I have received a letter—I have permission to quote it—from the specialist in 1463 community medicine of the Derbyshire Area Health Authority. He says:… it is difficult when the Area Health Authority gets a clinical opinion by a Consultant Psychiatrist that a particular patient is a danger to the public and in the absence of other secure provision being available requires admission to a special hospital, to make alternative provision if the application for special hospital is rejected by administrators in the D.H.S.S. While the clinical opinion may well be wrong, it does seem to me that the department ought to seek further clinical advice before rejecting such an application, and make the arguments available to those responsible for placement.That is exactly the position today. It is stated there by Dr. MacInnes very succinctly indeed. Here we have a potentially attractive human being of above average intelligence, who, if her personality could be probed, is capable of great friendship and warmth of personality, and she is not being helped because she is not receiving the back-up facilities which she ought to have, as those facilities do not exist. The people at Thornhill cannot help her unless there is more secure environment, and that is not provided by these endless visits to Risley and appearances at the magistrates' court, or by the family disasters.
I shall be more brief about the other case because it has not involved this cycle of events to which I have referred. It is the case of a young man whom I call Mr. Y, in his middle twenties. He had a personality disorder and epilepsy in a fairly mild and controllable form. He has on a number of occasions travelled around the country and has called in at a number of hospitals. I believe he has been to 80 hospitals in all. He is expert at simulating severe illness of one kind or another. He does a good line in cardiac arrest and pulmonary embolism. He can, particularly as he now knows the right answers to give to the questions, fool any specialist in the country for 48 hours. The admission procedure being what it is, it is a costly and frustrating game for all concerned.
This young man has a disorder, which he acknowledges. It is a disorder which has not as yet led to too much trouble or tragedy, although to his mother, with whom he lives, it causes great distress. His doctor wrote to me on 22nd January after correspondence which had gone on for some time, saying: 1464His tantrums are now becoming more frequent. Both my partner and I feel that there is an increased probability that under stress he will react violently and direct this violence towards his mother. He is in need of skilled psychiatric help but this can be provided only in a secure unit which is able to manage psychopaths. No such unit is available in the Trent Region. Perhaps you could enlist the help of the Minister of State at the Department of Health and Social Security or even the Secretary of State herself. I fear a tragedy.I have the presence, and I hope the assistance, of my hon. Friend the Under-Secretary of State, and I hope he will have seen the correspondence from our hon. Friend the other Under-Secretary of State dealing with this case and the difficulty of providing any kind of secure unit. When this young man has been offered appointments at hospitals he has turned them down, and this is always the situation. It is no good saying "The consultant psychiatrist will see him. If he kept his appointments and came in regularly to see us, so that we could prescribe the right balance of drugs and group therapy, he would be much improved." No doubt he would, but it is a feature of this disorder, and of the instability that goes with it, that the person concerned cannot keep to such a régime. He shies away from it. That is why I used the phrase "secure unit". By that I do not mean incarceration in drugged stupor and being shut away, as may have to occur in certain cases of chronic mental illness.
The only way in which a person with a personality disorder of this kind can be helped and treated is by the provision of a secure environment. That means the provision of the degree of restraint and in-patient care that is necessary. I realise that there are difficulties in treating personality disorders. I have come to know both the young people whose cases I have described—and their families—and I feel for them in a potentially tragic situation. They have been shuttled from one holding operation to the next. Their insecurity makes it unlikely that they will ever have a firm grip on what might be offered to them.
Given that there has been no particular response from the Area Health Authority to the appeals from the Department to put forward proposals for interim secure facilities attached to existing psychiatric hospitals, I hope that the Department will take steps to help these young people 1465 and others like them by offering that ultimate back-up which it is the job of central Government to provide.
§ Mr. James Scott-Hopkins (Derbyshire, West) rose—
§ Mr. Deputy Speaker (Mr. Bryant Godman Irvine)
Has the hon. Gentleman the permission of the Minister and the hon. Member for Derby, North (Mr. Whitehead) to intervene?
§ 3.46 p.m.
§ Mr. James Scott-Hopkins (Derbyshire, West)
I should be grateful if the hon. Member for Derby, North (Mr. Whitehead) and the Minister would allow me to speak for two minutes to back up what the hon. Member for Derby, North said.
I also come from Derbyshire, and I have had a similar experience—not quite so harrowing—to those related by the hon. Gentleman. My constituency is further to the north of the county, and it was impossible to find a secure environment for the constituent I have in mind whom I do not intend to name. He had to go for treatment to the Manchester area.
Derbyshire is in great need of a secure psychiatric unit where young people who are suffering from these disorders—unhappily the sufferers are nearly always young—can be kept under proper supervision and properly treated. We do not want iron bars—far from it. We want a stable, secure environment. Unfortunately, that does not exist. All consultants and doctors in my part of the world will back up what the hon. Gentleman and I have said, and I hope that the Minister will be able to give us a ray of hope even in these stringent economic times.
§ 3.47 p.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Michael Meacher)
I congratulate my hon. Friend the Member for Derby, North (Mr. Whitehead) on the lucid way in which, not for the first time, he has made such a strong case for his constituents. I am grateful to him for providing this opportunity to discuss the service for those patients who, although not having the dangerous or violent pro- 1466 pensities which would require their admission to special hospitals, cannot satisfactorily be managed in the ordinary wards of psychiatric hospitals. As my hon. Friend pointed out, these patients have been a source of increasing concern to central Government, to the health and local authorities and to the courts. My Department is keenly aware of the pressing need for appropriate accommodation for these patients and the requirements of the hard-pressed staff who carry the burden imposed on them by the disruptive tendencies of these patients.
It may be helpful if I briefly outline the background to the present situation. Let me say straight away that since the inception of the National Health Service it has been part of its responsibility to provide facilities to treat all types of patients with mental disorder, the only exception being those who require to be treated in conditions of maximum security. The Mental Health Act 1959 did not change this fundamental responsibility. The changes of attitude which it helped to promote have brought about a vast reduction in the number of patients formally detained, and in restrictions on patients' liberty. But there now seems a danger of this change of attitude being carried too far by some, to the point of reluctance to provide a degree of supervision and restriction that some patients clearly need, and to regard these patients as not being an NHS responsibility.
In recent years there has been a growing problem in a number of areas as more and more psychiatric hospitals have become entirely open door and have often not made alternative provision for the continually difficult, behaviourally disturbed patients who were formerly contained, no doubt not very satisfactorily, in locked wards. One consequence has been greater pressure on the special hospitals which are already over-crowded. In any case, they provide a greater security than necessary for these groups of patients. The Department does not wish to see a reversal of the trend towards more open care and treatment of the great majority of patients in hospitals for the mentally ill. However, places will still need to be made available in each region for patients requiring treatment in varying degrees of security short of that provided by the special hospitals.
1467 Because of mounting criticism, a Departmental Working Party was established in 1971 to consider the present and future needs for security and to make recommendations. Both the revised report of that Working Party and the Interim Report of the Butler Committee on Mentally Abnormal Offenders emphasised the urgent need for regional security units. Since then, the Department has taken vigorous action to encourage health authorities to meet this need. In July 1974 the Department issued a circular which asked all Regional Health Authorities to take urgent action to establish such units. The initial aim is to provide 1,000 places, either by adapting existing buildings or by constructing new purpose-built premises, and a special capital allocation will be made to regions for this purpose once proposals have been agreed.
In the meantime, before security units can be provided, authorities have been asked to designate certain hospitals to provide treatment on an interim basis for this group of patients in conditions which adequately meet their needs. All Regional Health Authorities have recently been investigating the position in their regions and a few authorities have submitted definite plans in the shape of formal planning submissions. However, in October 1975, the final Report of the Committee on Mentally Abnormal Offenders criticised the lack of progress in the provision of such units. The Report noted that, whilst consultations were proceeding in most regions, clear statements of intent were lacking in some, and recommended that in order to achieve more speedy progress the running costs as well as the capital costs should be met from central Government funds.
This recommendation has, I am glad to say, been accepted by my Department, and in February of this year Regional Health Authorities were told that the network of regional security units must be proceeded with forthwith and they were notified of the amounts of money which would be allocated to them in 1976–77. All Regional Health Authorities have been asked to produce proposals immediately and to proceed with the establishment of units as quickly as possible. The aim is for all regions to have permanent Units in operation by 1980. It is to be 1468 hoped that the authoritative backing of the Butler Report on the value of the units and the fact that the Department accepts that view and has agreed to fund them will result in more rapid progress than we have seen so far.
Now let me turn to the particular problems of Derbyshire and the Trent Region, to which my hon. Friend has referred. As to Security Units, officers of the Trent Regional Health Authority in August 1974 set up a working party to consider the provision of facilities for patients requiring treatment under conditions of security. They discussed various possibilities with officers of certain Area Health Authorities, including Derbyshire Area Health Authority, and the outcome was that the Regional Health Authority last year authorised a start to be made on the planning of a unit of about 60 places at the Towers Hospital, Leicester, to serve the Trent Region. The Regional Health Authority is pressing ahead with this unit but even so I am sorry to say that it is unlikely to be operational for possibly three or four years yet. I accept that that is disappointing, but we have to consider the extreme tightness of resources, to which reference was rightly made.
The Regional Health Authority is also discussing with the Nottinghamshire AHA (T) the possibility of finding a site for a unit of about 40 places to cater for mentally handicapped patients in the region requiring secure accommodation. My hon. Friend will be aware that two wards at Aston Hall Hospital near Derby are already formally designated as secure accommodation for severely mentally handicapped patients. In short, there is some progress to be reported concerning provision of security units in the Trent Region, even though it is not as fast as both the Regional Health Authority and the Department would have wished.
§ Mr. Whitehead
Aston Hall is not for people with personality disorders but for the severely mentally handicapped.
§ Mr. Meacher
I accept that the hospital unit to which I am referring has a different function from that which would be suitable for Miss X, to whom my hon. Friend referred, but I have indicated the situation concerning the security units. I shall be dealing with the interim units 1469 in the Trent Region shortly. Perhaps I should turn to that aspect now.
I have to say straight away that there is even less progress to be reported in the provision of interim security arrangements in the Trent Region. I am not suggesting that the Regional Health Authority does not accept the responsibilities placed upon it by my right hon. Friend in this respect. Indeed, it is on public record as fully supporting departmental policy in this matter, and has expended a good deal of time and energy in the last 18 months or so in trying to ensure, in conjunction with Area Health Authorities, that interim arrangements are made whereby particular hospitals are designated to provide treatment in conditions of security until such time as proper regional security units can be provided.
It is with considerable regret that I have to report that over the past 18 months the Regional Health Authority in consultation with the Area Health Authorities—in spite of repeated and conscientious efforts to this end—have been unsuccessful in their attempts to designate interim accommodation for this purpose. Quite recently the Regional Health Authority has made a further effort in the case of three Area Health Authorities, including Derbyshire, to designate interim accommodation for this purpose, and linked the request with an offer of both capital and revenue funds. Unfortunately, Derbyshire Area Health Authority has not felt able to agree to the Regional Health Authority's request and replies from the other Area Health Authorities so far approached are still awaited. In the meantime, the Regional Health Authority continues to receive requests for the accommodation of disturbed patients—including those with personality disorder, to whom my hon. Friend referred—and it is urgently considering what steps it can now take to enable it to meet its responsibility for providing this service.
It is only fair to point out that both proposals by the Regional Health Authority and Area Health Authorities for the designation of hospital beds for interim security purposes have met with considerable resistance from some medical, nursing and other staff. It must 1470 be recognised that some professional staff are genuinely doubtful about the merits of providing secure accommodation in existing psychiatric hospitals and feel that such a move is both retrogressive and might harm the good name of the hospitals in which they are working.
It must also be conceded that whether or not a person's disorder requires or will respond to medical treatment is a matter of clinical judgment, and differences of opinion between doctors in individual cases can and undoubtedly do arise from time to time. This is particularly relevant in the difficult field of personality disorder to which my hon. Friend made so much reference, and the final decision must rest with the doctor who would carry out treatment if the patient were admitted to hospital.
The Butler Report stresses that psychopathic offenders present particular difficulties to the health services. Where treatment and facilities are offered but repeatedly rejected, and where any future law-breaking is likely to be minor or of nuisance value only—I think that is the case to which my hon. Friend referred—the Committe thought that it may be right to accept that the offender was not susceptible to rehabilitation, and that the official services should consider whether continuing attempts to help would serve a useful purpose. As we said in our recent White Paper "Better Services for the Mentally Ill", we need to think very carefully about this whole field, and we are currently considering the need for further research and new approaches to this very difficult problem.
We feel that all that can be done by central Government to assist in the speedy provision of these facilities has been done within the very limited resources which are available. What is required now, I think, is for health authorities—this is not to be underestimated—with the full backing of the Department already given both as to policy and to finance, to redouble their efforts to win the co-operation of the staff, which should not be neglected, and to establish both the interim and in due course the more permanent security arrangements which, as my hon. Friend eloquently described in these two cases are so urgently needed.