§ Mr. Patrick Jenkin (by Private Notice) asked the Secretary of State for Social Services if she will make a statement on the Report on St. Augustine's Hospital, Kent.
§ The Minister of State, Department of Health and Social Security (Dr. David Owen)
This inquiry was commissioned by the South-East Thames Regional Health Authority and the Report of the Committee is to the RHA. The chairman of the Authority has issued a full statement today, and the RHA as a whole is to consider the findings and recommendations of the Committee at its 1307 next meeting on 15th April. I feel, therefore, that I should limit my comments at this stage to those matters which are the immediate and direct responsibility of my Department. I have placed copies of the Report in the Library. My right hon. Friend the Secretary of State is to visit the hospital shortly.
There are three main matters which the Report suggests that the RHA should consider drawing to the attention of the Secretary of State. The first is the need to develop and extend the work of the Hospital Advisory Service. The Government totally accept this. The Report states in paragraph 4.45 that if the Hospital Advisory Service recommendationshad been fully discussed and implemented there would have been no critique.In paragraph 4.50 the Report calls attention to the difficulty of having an advisory team—in this case the Region—too close to those whom it is advising.The Report also asks for the HAS to make regular visits every three years to hospitals for the mentally ill. The HAS has always made follow-up visits to hospitals where it thought it appropriate and has been ready to answer requests for visits where it can.
The Government announced on 31st July 1974 that we intended consulting on a wider remit for the HAS and changes in its functions. These consultations have now been completed. A circular will be issued very soon. The Hospital Advisory Service will be called a Health Advisory Service; it will continue to concentrate on long-stay services but will have social work service participation and cover community services as well as hospital services. The HAS in future will have direct and closer contact with field authorities, particularly in regard to follow-up. It will in future follow up its reports with health authorities in all cases, resolving problems and differences as far as possible at a local level, but where matters give rise for concern the service will be expected to exercise its right of access to Ministers.
The second point relates to the exchange of patients between special and National Health Service hospitals. It is not the Department's policy that the admission 1308 of patients from NHS hospitals to the special hospitals should be conditional on the NHS hospitals in question accepting in return a special hospital patient. However, if there is a special hospital patient already on the waiting list for transfer to the hospital concerned, it is usual to ask whether the hospital is prepared to accept the patient in question. Yet the House must face the fact that there is a great shortage of specialised secure accommodation.
The Government are making earmarked money available to regions for the early development of regional security units. A special capital allocation of £2.5 million annually is being provided. Special assistance amounting to over £4 million revenue is also being made available to RHAs annually from 1976–77 to help them develop their regional security units and interim facilities until the units themselves are ready.
The third matter related to the question how far the suggestions in the Report for better management in relation to St. Augustine's Hospital should be applied to other psychiatric hospitals. There is little doubt that there will be aspects of wider application, and we shall consider what action will be necessary in the first instance with the South-East Thames Regional Health Authority, and then with all health authorities.
What this Report emphasises yet again is the necessity for a higher priority to be given than in the past to mental illness services. It is a salutary lesson that, for all the talk in this House, and outside about the priority for the mentally ill, the proportion of total health and personal social services devoted to mental illness actually dropped from 8.2 per cent. in 1970–71 to 7.8 per cent. in 1975–76, although there was nevertheless an increase in real terms in resources devoted to the mentally ill throughout that period.
The Consultative Document on Priorities for Health and Personal Social Services which we issued last week proposes that services for the mentally ill should be a major priority area for the years until 1979–80, and we have recommended that expenditure on mental illness services should increase so that its proportion of total health and personal social services expenditure should rise to 8.2 per cent. by 1979–80.
§ Mr. Jenkin
I thank the Minister of State for that long reply. Although the whole House will wish to acknowledge that much fine work is done in our mental hospitals, including St. Augustine's, is not the Report yet another example of gross shortcomings brought to light only by dogged perseverance on the part of one or two individuals?
Is the Minister of State aware that the Government have had the Davies Report on Hospital Complaints Procedures since December 1973, and that my right hon. Friend the Member for Leeds, North-East (Sir K. Joseph) set up that Committee expressly as a result of the Ely, Farleigh and Whittingham disclosures? Did it not take the Government until February 1976 even to accept in principle the main recommendation that there should be a code of practice for handling complaints? When will the Government implement in practice the main proposals of the Davies Report?
My second question relates to the care of the long-stay mentally ill. Does the Minister of State recollect that the Committee of Inquiry into the South Ocken-den Hospital urged that the Department should issue guidance to regional authorities on the care of the long-stay mentally ill and that even now, three years later, no such guidance has been issued? As neither of those matters involves public expenditure, may we ask the Government to deal with both with a greater sense of urgency?
When the Minister of State points to the record of my right hon. Friend the Member for Leeds, North-East, may I in turn point to him and say that the rise in real terms in expenditure on the care of the mentally ill was at exactly twice the rate during the period of office of the Conservative Government that is proposed in his right hon. Friend's booklet on priorities for the next five years?
§ Dr. Owen
I am grateful to the right hon. Gentleman for Wanstead and Woodford (Mr. Jenkin). In reply to his last comment, I was not making a political point. There is a great deal of commitment on both sides of the House to the cause of the mentally ill and the mentally handicapped. What we all know is that we have to choose, and I think the figures I have shown indicate that, despite having made the decision to give it priority 1310 —I gladly pay tribute to the rising percentage of expenditure on the mentally handicapped in the period in question—it was not possible to increase the percentage in relation to the mentally ill.
Concerning the right hon. Gentleman's first point about the Davies Report, the problem for us arising from that Report is that the professions—and in particular the medical profession—have been very concerned about many of its recommendations and asked for a longer period for consultation than is normal. The Government felt, in view of the very strong feelings which the medical profession held about the Report, that they should extend the period for consultation. That was the prime cause of the delay.
We have accepted one of the Report's major recommendations. Relating to the whole question of setting up the special review boards; we have asked the Select Committee of the House of Commons which deals with the Health Commissioner to look at the whole question of the remit of the Health Commissioner, in order to try to avoid an overlap of investigative bodies in this area.
As to the South Ockenden Report, which related to hospitals for the mentally handicapped, there is a need for the code, and I agree with the right hon. Gentleman that that would not require resources. It has again taken time to get agreement within the nursing profession, the medical profession and others on what can be done in this area. But I recognise that there is an urgency.
§ Mr. Crouch
I declare an interest, in that St. Augustine's Hospital is in my constituency. I know it very well and have visited it many times. As a member of the South-East Thames Regional Hospital Authority I have an added interest in the Report.
I declare to the House, too, my very great concern at what the inquiry has revealed as to the conditions at St. Augustine's Hospital and the care of patients. But I should like to draw to the attention of the Minister of State that in the foreword to the Report—and the Report is about a small part of the hospital and not the whole of it—the Committee of Inquiry states that, with very few exceptions, all those whose performance has been criticised were doing their best.
1311 I point out to the Minister and to the House that it is not just a question of money, although more money has been put into St. Augustine's Hospital than into any other psychiatric hospital in the South-East Thames region. The problem is that it is an isolated hospital, as all old mental hospitals are. They were designed to be isolated at a time when the tendency was to put the mentally ill away from sight. If we were today to implement the good intentions of the Government—indeed, of all Governments, as pointed out by my right hon. Friend the Member for Wanstead and Woodford (Mr. Jenkin)—towards achieving a better standard of care and conditions for the mentally ill, it would in this region alone cost not less than £200 million to implement a better system of attaching the psychiatric wards to the main stream of the Health Service, instead of isolating them.
Equal to my concern for patients is my concern for what the nurses and the other staff in a mental hospital have to put up with, particularly in long-stay wards, where they are dealing with violent patients and patients who are doubly incontinent.
We should keep in mind that the Report is a constructive one. I am helped by the Minister of State's response, which was very constructive, to the effect that we shall use the Report for the purpose for which it was intended, namely, to help us improve conditions. No one wishes to condone the mistakes. We wish to go on to improve conditions, not only in this hospital but elsewhere.
§ Dr. Owen
I agree with the hon. Gentleman that it is a constructive Report. I think that all of us in the House have to be careful, when such reports reveal grave shortcomings, that not all the criticism focuses on the staff. The staff work in very difficult circumstances, often in very old buildings, isolated—as the hon. Gentleman has said—and dealing with a very large number of patients. We have to recognise that some of these patients are also violent, and that there is a strong case for them to be treated in more secure accommodation, or in special hospitals.
I share with the hon. Gentleman the feeling that more money will be needed 1312 but that money is not the only answer. When talking of better services for the mentally ill, we must try to recognise that many of these large psychiatric hospitals will be making a contribution to the National Health Service for 15 or 20 years. They must have resources, part of which must be capital, in order to improve the fabric in which patients live.
§ Mr. Pavitt
I welcome my right hon. Friend's statement about the extension of function of the Hospital Advisory Service, the importance of which cannot be over-emphasised.
In considering the consultative document—my hon. Friend has already said that there will be massive increases in this area in the next four years—in terms of priorities, will the emphasis still be on the staff rather than buildings, in spite of the fact that more buildings are needed? Will my right hon. Friend confirm that the spotlight is always placed on the things that go wrong and that there are many thousands of devoted charge nurses and doctors who spend their lives in the service and to whom no praise whatsoever is given?
§ Dr. Owen
I agree with my hon. Friend as to the tremendous devotion shown by the staff in hospitals dealing with the mentally ill and the mentally handicapped, and in particular with the long-stay patients. However, I must add a word of caution. The consultative document, to which my hon. Friend referred, indicates only what could be and should possibly be spent on the mentally ill. It will be spent, as past history shows, only if there is a great deal of commitment throughout the Health Service and throughtout the country to giving this area a higher priority than it has been given hitherto.
§ Sir George Young
The Minister explained that the problems arose from the failure to implement the Report of the Hospital Advisory Service. How many Reports prepared by the Service concerning other psychiatric hospitals have not as yet been implemented?
§ Dr. Owen
I do not want to prejudge the question. There have been some failures of implementation. The criticisms about the follow-up of Hospital Advisory Service Reports have some substance. It is in order to try to get a 1313 better follow-up process—which involves the Hospital Advisory Service initially and then, if necessary, reporting back to Ministers—that we have made changes.
§ Mr. Moonman
The Report gives a most terrifying account of mental hospital life today. My hon. Friend will appreciate that although one does not wish to make a general criticism of nursing staff, it would be equally wrong to ignore the responsibility in this case for the brutal treatment of patients. Will my hon. Friend not take into account the way in which the recruitment, selection and training of nursing staff are carried out in the future, as that is crucial?
§ Dr. Owen
I share, as I am sure the whole House does, my hon. Friend's concern. There are matters in the Report to which the House will no doubt wish to return, as they give cause for great concern. Staff training has improved substantially in the past decade or more, but I agree that there is scope for greater improvement and that that is the way forward.
§ Sir D. Walker-Smith
I give a general welcome to the Minister's intention to seek to expand the resources allocated to mental health, and in particular I hope that he succeeds in getting greater real expenditure on it, but is there not a particular problem with the long-stay wards in the old hospitals? Will the Minister give all possible priority to that from the point of view, among others, that better accommodation and facilities are necessary for the encouragement of the recruitment of well-trained and enthusiastic staff?
§ Dr. Owen
I agree with the right hon. and learned Gentleman. We owe it to the staff to provide better facilities if we are to keep their high sense of commitment. Long-stay wards face considerable problems because of overcrowding. We need to be able to get patients out of hospital and back into the community in order to free accommodation within hospitals. That is why we cannot look at the problems of the mentally ill in isolation. It is not just a problem for the National Health Service. It is also a problem for the local authorities, and particularly the personal social service departments.
Dr. M. S. Miller
Does not my hon. Friend accept that there are far too many cases of this kind for any degree of complacency by this House and that this seems to be a case of one flying over the cuckoo's nest? There is an element of going back to the Middle Ages in some of our mental hospitals, and a civilised and compassionate Government cannot accept that there should be any kind of thuggery involved in dealing with patients who are in no way capable of looking after themselves. Would not my hon. Friend consider setting up a special committee to investigate the possibility of seeing that doctors, nurses and other staff who deal with patients of this kind are people of the highest integrity with the special skills to enable them to deal with their patients?
§ Dr. Owen
My hon. Friend knows, probably better than most, the problems that we face in this area. We are reviewing the working of the Mental Health Act, and we shall be happy to take any evidence and facts into consideration in looking at what future legislative changes may be made. As for my hon. Friend's question about the commitment of staff, I frequently tour the country and see staff working in these very difficult circumstances, and I pay tribute to their dedication. But sometimes things go wrong, and we should not tolerate them when they go wrong, especially when they involve questions of violence. However, we have to understand sometimes the provocation under which the staff work.
§ Mr. Moate
Without wishing to cast any doubt on the conclusion of the Report, will the hon. Gentleman accept it from me, speaking, as I do, as the Member for a neighbouring constituency who has seen and corresponded with many people who have received treatment at St. Augustine's, that I have never heard suggestions or complaints of bad care or treatment? Although undoubtedly there are lessons to be learned from such Reports as this, will the hon. Gentleman emphasise equally one important point which is made in the Report, to maintain public confidence and staff morale in these institutions? I remind the hon. Gentleman of the statement to the effect that the Committee of Inquiry is confident that staff have the skills and ability to solve these problems and that any 1315 patient can now enter St. Augustine's with confidence that he or she will be satisfactorily cared for and treated.
§ Dr. Owen
I gladly give a reassurance to the hon. Gentleman's constituents. Many changes have been made already over the past year or two. There is no doubt that criticism relates to some parts of the hospital. But much of this criticism could be made of any other hospital. It is not unique. I wish that it were so.
§ Several hon. Members rose—
§ Mr. Christopher Price rose—
§ Mr. Speaker
Order. It is discourteous for an hon. Member to remain standing when the Speaker rises to his feet. I must ask hon. Members to make their questions as brief as possible. I know that this is a very important matter, but we have an enormous amount of business before us today.
§ Mr. Christopher Price
I apologise for any discourtesy to you, Mr. Speaker. May I ask my hon. Friend whether he is aware that it is not primarily resources which are needed at the moment so much as clear advice from his Department not only in response to the Davies Report but over the whole area of patients' rights and compulsory treatments? Is he aware that although great regard should be paid to the rights of the staff to proper consideration, doctors should not be allowed permanently to prevent my hon. Friend's Department giving this clear advice to psychiatric hospitals up and down the country?
§ Dr. Owen
This issue relates to clinical freedom and to matters of clinical judgment. It is right that a Select Committee should look at the remit of the Health Service Commissioner to see whether he can, with advantage to everyone, while safeguarding the professions which naturally wish to preserve their rights, look at questions of clinical judgment. This will be for a Select Committee to report upon, and I do not wish to prejudge its findings.
§ Mr. Rees-Davies
Further to what was said by my hon. Friend the Member for 1316 Faversham (Mr. Moate), with which I agree entirely—we in Thanet have had very few complaints about St. Augustine's—I should like an assurance from the hon. Gentleman. Is he satisfied that, following the recommendation of the inquiry and of the Inskip Report, the position now is satisfactory in those areas with which they dealt and that the scarcity of money and other resources will not stand in the way of clearing up complaints made in this Report?
§ Dr. Owen
It must be said in fairness to the Regional Health Authority that it faces many conflicting pressures on resources. But I hope that in reviewing this Report it will be possible to find a high priority for the demands of hospitals such as this. However, the country must understand that, if we invest in this area, the money cannot be spent in other areas. There is a limit on the amount that we can spend overall on the National Health Service. We have to ask ourselves what is the priority. I think that the judgment of this House is that the mentally ill should have been given in the past and should be given in the future higher priority than hitherto.
§ Mr. Costain
Like my hon. Friend the Member for Faversham (Mr. Moate), I have a neighbouring constituency, and I have had no complaints for a number of years about this hospital. However, there is general dissatisfaction in this area about the whole set-up of the hospital service. Will the hon. Gentleman take an early opportunity to visit my area in order to investigate the position for himself?
§ Mr. Peter Rees
Although I welcome the hon. Gentleman's statement and his promise of special assistance, will he recognise that there is a shortage of and therefore a need for day care units for the mentally ill in East Kent and that special assistance should be directed to this area, which might ease the transition back to normal life for the mentally ill, which we know to be one of the hon. Gentleman's objectives?
§ Dr. Owen
I agree with the hon. and learned Gentleman that it is vital to provide better community services. I hope that the measures which we are taking for joint financing between the health and personal social services through the mechanism of the joint consultative committees will ensure that we get, even at a time of considerable constraints on public expenditure, some improvement in facilities such as day care.
§ Dr. Reginald Bennett
Can the hon. Gentleman say whether the medical and supervisory staff were up to establishment at the time of these events?
§ Mr. Patrick Mayhew
Does not the Report say in paragraph 1.20 that in the long-stay wards there was either a complete absence of policy or the formulation of policy was carried out by nursing staff without encouragement or guidance? Did not the South Ockenden Report three years ago call for central guidance into the operation of multi-disciplinary teams in the hospitals for mentally handicapped patients, and is not the failure on the part of the Government to do anything about this quite disgraceful?
§ Dr. Owen
I think that we would all be well advised not to make this a political issue. Mental handicap, such as at South Ockenden, raises very different issues from mental illness. What is at issue is the question of clinical freedom and the extent to which central Government can direct doctors. The Government have published "Better Services for the Mentally Ill", built in part on the work which was done in the Department by the previous Secretary of State, and he published "Better Services for the Mentally Handicapped", built on work done by Dick Crossman when he was Secretary of State. I think that we would all be well advised to ensure that these two areas are given higher priority 1318 than hitherto, and perhaps the House should expect doctors themselves and other medical professions to look at their practices not in the terms used in paragraph 1.20 of the Report of laissez-faire.
§ Mr. Aitken
Is the Minister aware that one side effect of this disturbing Report could be that St. Augustine's Hospital will be under pressure to ease its overcrowding problems by increasing the number of mental patients discharged to neighbouring communities? In those circumstances, will he take special precautions to ensure that no one community is overloaded with an excessive number of these patients and will he recognise in particular that the community of Thanet already has special problems in this respect?
§ Dr. Owen
This is one of the difficulties of a very large hospital discharging patients to what may be a small catchment area. As I say, there is a necessity to look at community services in relation to hospital services, particularly in the case of long-stay patients, and I hope that this can be done. But I must say to both sides of the House, especially to the hon. Member for Thanet, East (Mr. Aitken), that this costs money. It is no good advocating reductions in public expenditure and then expecting people to provide additional services.