HC Deb 05 May 1976 vol 910 cc1431-44

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Frank R. White.]

10.32 p.m.

Mrs. Lynda Chalker (Wallasey)

I am especially grateful for the opportunity to raise the issue of the community care of the mentally sick and handicapped. It is a very special issue, and it is only the second time this year that we have debated mental health and the mentally handicapped. Indeed, it is only the second time that we have done so for the two years and more that I have been a Member.

This debate comes at the commencement of the MIND campaign, whose slogan is Help a healthy mind leave hospital". At the outset I must declare an interest. I am a member of the MIND General Council. For some years I have had a close interest in the problems of the mentally handicapped and in mental health. Many people have asked why I should try to deal with both the mentally ill and the handicapped in the one debate. I do so because I am concentrating on the community care aspect, which allows them to go back to the community to live as normal a life as possible in view of their previous history.

There are about 50,000 mentally handicapped still in hospital, and the Government estimate that between one-third and one-half of them need not be in hospital but could live in the community with support. The most terrifying figure of all is that about 6,000 mentally handicapped out of the 50,000 are children who could most certainly live in the community to a greater extent than is presently possible if there were additional aids.

The Under-Secretary of State will be aware that I am interested in supporting the payment of the attendance allowance to foster parents who are prepared to take mentally handicapped children into their homes. I was delighted by the chink of light which appeared last week in the Chamber when the Government said that they are actively considering the 300 mentally handicapped children who are looked after by foster parents. I hope that that chink of light will soon be the beam of the full attendance allowance for those foster parents.

There are some 600,000 people receiving psychiatric help every year. We know that by the time they are 45–50 years of age, one in six women and one in nine men will have benefited from some psychiatric help. A large and increasing number seem to be needing longer care and greater support back in the community. Over 70,000 have spent more than two years in a mental illness hospital, and 32,000 have spent at least 20 years in such hospitals, often in large units of 1,000 beds or more. Comparing all these figures, I must ask, why is it that many of these people remain?

During the last year I have spent some time looking round the mental hospitals in the North-West. I found that many people—including a former constituent of my predecessor—are there because they have no homes to go to and none can be provided. Having found the first case, one then finds an increasing number of people who have no need of psychiatric hospital care but just need a home and support within the community.

A comparison of our spending in 1973–74 of £300 million on hospital care of the mentally ill against £15 million on personal social services and £6.5 million on day care tells us that our priorities seem to be in the wrong direction.

In 1960 the then Conservative Government made a firm commitment to bring back into the community people who no longer needed institutional care. In 1971 we had a Command Paper about the care of the mentally handicapped. In 1975 we had another Command Paper on better services for the mentally ill. But all this time there has been minute progress in selected areas towards giving these people the chance to start to re-live life, which is what we are talking about.

We have made great advances. Nobody denies that 1½ million out-patients per annum and 2 million attendances per annum at day psychiatric centres is an advance. But we have a problem. The growing number of psychiatric nurses is only in certain areas. People are not encouraged in their nursing careers to go into psychiatric nursing in anything like the numbers that we need, particularly when we consider the community psychiatric nursing sphere.

The second reason for tackling these two areas together is that the community support required for someone who has been in an institution does not differ immensely between the handicapped and the ill. There are great similarities. The main requirement is to relieve the relations or the family with whom the person becoming rehabilitated is now living, to give personal support, and to help to create the one-to-one relationships from which that person has been severed for so long.

We know the money situation only too well. It is not for me to call for further Government expenditure, but I call for a reallocation of finances. I particularly welcome the consultative paper on joint financing. I have only one fear. If anything, it is a bit tentative.

I look forward to seeing how the Under-Secretary of State, with his right hon. Friend, will impress not only on area health authorities but also on local authorities the importance of being able to utilise buildings which are no longer needed in the hospital service for the community service and how funds currently allocated for the hospital service can be better deployed in providing greater community support for those who should have the right and chance to live at home.

In this context I should like to place a few figures before the House. The cost of hospital places in psychiatric care, on the estimates which I have been able to achieve, is now upwards of £46 per week, without including the drug therapy cost. The cost of hostel accommodation. by comparison, ranges between approximately £25 and £30 per week—again, without the drug cost. The cost of accommodation in small group homes, which a few local authorities have already begun, ranges between £15 and £20 per week.

I am concerned that we should be cost effective in our deployment of the mini- mal resources which we have at present. But I must remind the House that the proportion of expenditure on the mentally handicapped and the mentally ill will have to increase in the community sector. We have been decreasing capital expenditure in the National Health Service field at a time when revenue in the community sector actually requires to be increased. It is that sort of deliberation that is not spelled out clearly enough in our paper on joint financing, which is coming before local authorities, community health councils and area health authorities at present.

We have some very severe problems on both handicap and mental illness, and it is to deal with these that we have to adjust the financial resources. I mention but one in the mentally handicapped field to which I seriously ask the Under-Secretary and his colleagues in the Department of Employment and other relevant Departments to turn their attention. What happens to a mentally handicapped person at the age of 16 when he has received a special education and is suddenly plunged back on to the resources of the family alone? He may not get an adult training centre place, because many of these people suffer from double incontinance—and we are still not coping with that problem well enough. Therefore, suddenly, after 11 years of special schooling, the family is forced to cope with an adult who has had little training, who has little chance of even sheltered workshop occupation and who does not know what to do with his time, whom the family are desperate to help but do not know how to help. It is in this regard that support services for the mentally handicapped are perhaps the most pressing need.

I commend to the Under-Secretary the sort of schemes—perhaps he will take them up with his hon. Friend the Minister of State, Department of Employment—that are operating in other countries, such as Holland and Germany. In Holland there are sheltered workshops alongside factories. Philips is one example. Colour television components are made in sheltered workshops by mentally handicapped persons for assembly on the Philips television production line. This works very well. There are small beginnings in this country. Firms such as Belling and Lee, in Enfield, have sheltered workshops.

However, I have been able to find only three examples in the United Kingdom.

I turn from the mentally handicapped to the mentally ill. I remind the House of some relevant figures. Of the 180,000 who leave hospital each year, some are short-stay patients. However, the transfer back into the community is beset with problems—as we have seen with various Press exposes in Birmingham, Margate and other places; and they have not yet all come to light, by many means, and we know greater problems. We have a problem because there is a willingness in the mental health field to discharge patients back into the community, but the difficulty is that support services from the local authority are not there, or if they are there for the first week, they do not continue beyond that first week.

Frankly, I feel that it is necessary to say to consultants "Unless you are satisfied that there will be adequate community support, you are doing a disservice by discharge at this time to that particular patient." It is a hard thing to say because many patients are well and truly ready to come back into the community, but to leave them, as some men and women are often left, in both city centres and coastal resorts is more cruel than to keep them for a few more months in our hospitals.

The last thing we want to encourage is the revolving door syndrome. The best way to avoid people having to go in and out of hospital—and two-thirds of admissions to all mental illness hospitals are re-admissions; only one-third are first-time admissions—is to ensure that grants to excellent organisations such as the Richmond Fellowship, and some of the others working to give support to and put a roof over the heads of ex-mental patients, are not cut by local authorities. I do not know the best way of doing that. It is certainly something that I am examining, but I do not have the resources of the Civil Service behind me to help me to do it. I hope that the Government are already examining how we can make the best use of the 120 social clubs that MIND and local health organisations run, and the 20 day centres, too, and how we support the Richmond Fellowship which provides many of the hostel places for the mentally sick. There are only 45,000 hostel places in England and Wales and about 35 per cent. of them are provided by voluntary organisations. Yet, be- cause of our other problems, it is the grants to these organisations which are the easiest to cut.

There are many organisations in this field deserving of the highest praise. I call them the sharp end charities. Groups such as CHAR, SHAC, SHARP in Liverpool and the Cyrenians do excellent work, but they cannot do it all. They seek to share the problems of the mental patients, to give them guidance, to teach them to mix with other people and to look after themselves.

A local authority in my constituency has turned what used to be an ordinary hostel, which fed, clothed and looked after patients, into a rehabilitation hostel. The lady who runs it teaches mental patients to cook, clean, shop and sew and the ladies to do their hair. In short, she teaches them to live again.

This is the sort of small project which I want the Government and local authorities to encourage on a far wider scale. We can make a start in preparing patients for discharge into the community by making their nurses into teachers, friends and counsellors. When they move to the first stage of a discharge—for example, a hostel—they will learn far more quickly how to cope with the rigours of everyday life.

We must try to persuade local authorities to provide more homes where four or five patients can live together and form their own family group with support from local organisations for mental health and from social service departments.

It would be wrong for me to go on for too long. I want to leave time for my hon. Friend the Member for Hertfordshire, South (Mr. Parkinson) to say a few words and for the Minister to reply.

Above all, I suggest that the Minister must know that many false economies are being made and that grants are being cut to organisations which are doing productive work. Let the Minister look very carefully at the situation so that we may make the MIND campaign of bringing a healthy mind home from hospital more than just a catch phrase. Let us make it a reality. It will take determination and purpose to do so, but I am convinced that we can do it by pulling together. I hope that, with the joint financing document and good will on all sides, this can be done in the next five years.

10.48 p.m.

Mr. Cecil Parkinson (Herefordshire, South)

I congratulate my hon. Friend the Member for Wallasey (Mrs. Chalker) on her choice of subject for this debate, thank her for allowing me to intervene and congratulate her on an excellent speech.

I shall be brief because I want to leave the Minister time to reply. The biggest job we all have is to persuade local authorities that the provision of places for the mentally handicapped i. not an option but a necessity.

We know that the Minister is not responsible for housing and that he will have to work through hundreds of local authorities. Housing is the key shortage. There is a desperate shortage of buildings into which patients can be discharged and roofs under which they can live after leaving hospital. Our biggest task is to persuade local authorities to face up to the scale of the problem and to their responsibilities.

I should like to say a great deal more, but I must allow the Minister to reply.

10.50 p.m.

The Under-Secretary of State for Health and Social Security (Mr. Eric Deakins)

I welcome this opportunity to discuss our plans for the development of services for the care of the mentally handicapped and mentally ill outside hospital, and I am most grateful to the hon. Member for Wallasey (Mrs. Chalker) for raising the matter. I found her speech and that of the hon. Member for Hertfordshire, South (Mr. Parkinson) in the debate in January very interesting. I have read them in the Official Report, as I was not present because I was then working in another Department.

The Government's long-term strategy and their commitment to increasing community services in this area is already well known. It was stated in detail in the two White Papers to which the hon. Lady referred, published in 1971 and last year. Both make clear that in our view mentally handicapped and mentally ill people should be cared for as far as is practicable within the community, that when hospital treatment is needed it should be available locally, near the patient's home and family, and that people should not have to remain in hospital if they do not need the medical and nursing care provided there but should be encouraged to return to as normal a life as possible outside in the community.

I say "our view" advisedly. This is not a party matter. The former White Paper was published by a Conservative Government and the latter by a Labour Government, and both had been set in train by previous Governments.

But, as my colleagues have emphasised again and again, discharge policy must be realistic and must take account of the availability of facilities outside hospital for the continuing care and support of the patient. This is particularly important for people who have spent a long period, even many years, in hospital, who are likely to need some help in adjusting to life outside at least for a short time after discharge and in some cases—both with the mentally ill and the mentally handicapped—for an indefinite period.

We have made it clear that although it is primarily for the responsible consultant to determine when a patient is ready to leave hospital, good practice requires that before any patient is discharged the consultant should satisfy himself that there are adequate support facilities—this does not just mean a place to stay—outside the hospital.

The two White Papers spell out in some detail the range of services that will be needed if this pattern of community-based care is to become a practical reality. Residential accommodation, domiciliary services, day care and training, employment rehabilitation services, sheltered employment and social work support all need to be developed.

At the moment it has to be admitted that we have a long way to go, and community services, for the mentally ill in particular, are far short of what is estimated to be required. As recently as March 1975, for example, nine local authorities in England had no residential accommodation and 27 no day care facilities for the mentally ill. As a result it must be confessed that there are still considerable numbers of people in mental illness and mental handicap hospitals who do not need hospital in-patient care and treatment but who had little alternative but to stay there because there are no facilities for their accommodation and continuing support outside.

Even in favourable economic circumstances there is so much to be done that it would take many years of effort to build up community services for the mentally ill and mentally handicapped to the level that is needed. Given the present financial situation and the restrictions of local authority spending, we must face the fact that progress is bound to be more difficult. The rate at which progress can be made will depend not only on the overall level of resources that can be made available but on the degree of priority that can be given to the development of services for the mentally ill and mentally handicapped in the light of other pressing needs.

Mrs Elaine Kellett-Bowman (Lancaster)


Mr. Deakins

I shall not be able to answer all the points raised if I do not continue. I much regret not being able to give way.

The consultative document, published in March this year, attempted to establish rational and systematic priorities throughout the health and social services for the next few years up to 1980. In it we made clear that in our view services for the mentally ill and mentally handicapped, should be regarded as a major priority and suggested an increased allocation of both current and capital expenditure towards meeting the needs of these groups so that progress can be made.

The consultative document lays particular emphasis on the need to shift the balance of expenditure between hospital and community and to develop community services, both for day care and residential accommodation. For the mentally ill it proposes increased local authority capital expenditure totalling £7 million a year—£4 million on day centres and £3 million for residential care. In the mental handicap field we have been able to suggest an allocation which will mean the local authority capital development programme envisaged by "Better Services for the Mentally Handicapped" being maintained with an additional 2,400 adult training centre and 1,000 residential places being provided annually.

The document also emphasises the importance of making the most of existing resources by concentrating on relatively inexpensive, though nevertheless effective, solutions such as using adapted rather than expensive purpose-built premises, boarding out and supervised lodgings schemes, group homes and other kinds of sheltered accommodation and the use of voluntary effort, particularly in befriending and support schemes, to supplement the hard pressed statutory services.

There are already a number of examples of schemes, in this country and elsewhere, which illustrate how successful this kind of approach can be if handled in the right way, with the full co-operation of the health and social services. One such successful and lone-established scheme has been in operation in some form for several hundred years in the town of Geel in Belgium, where a large-scale fostering or boarding-out scheme, with supporting day care and social work facilities, enables large numbers of mentally ill and mentally handicapped people to live in private households as members of the family. Attempts to establish similar schemes on a smaller scale, in this country, have also been successful, one recent example being a project in Salisbury which enabled over 100 patients who had been in hospital for many years to be discharged to private homes.

Group homes, where five or six people can live together as a family, organising their own finances and household chores, with no residential staff, and only occasional visits from a social worker or voluntary worker, have also been developed most successfully, by local authorities and by voluntary organisations, to provide accommodation for people who have been in hospital for some years and who cannot manage to live entirely on their own. I am thinking, for example, of the scheme established in Dorset for patients from Herrison Hospital, of MIND's many group homes and of those set up in the Midlands under the auspices of the Guideposts Trust. These are examples in the mental illness field, but similar initiatives have taken place in respect of mental handicap.

I have already mentioned the valuable part that voluntary organisations can play in the care of the mentally ill and mentally handicapped. This is fully recognised in the White Papers and the consultative document on priorities. MIND's "Home from Hospital" scheme is an excellent example of the approach that we have been urging. The campaign will aim to make full use of MIND's extensive network of local groups to set up group homes, befriending schemes, boarding-out arrangements and day care and social club facilities to help some of the large number of people at present in mental illness hospitals to return to the community. My Department has made a grant of £20,000 to help launch this scheme and I am confident that it will make a considerable impact on the present severe shortage of community facilities, especially for the mentally ill.

For this, and similar schemes, to be successful it will be essential that there should be full collaboration with all concerned, and I was particularly pleased to see that MIND has laid considerable emphasis on this aspect of its campaign.

However, if we are to see real improvement in the level of services for the mentally ill and mentally handicapped we must not rely entirely on voluntary effort, valuable as this is. Joint planning and collaboration between health authorities and local authorities will be of crucial importance and is an aspect which we have repeatedly emphasised. We have just issued a consultative circular outlining for local authority and health interests our proposals for joint planning and for the joint financing of agreed projects which both the health and local authorities regard as of high priority. Of course, this arrangement cannot be expected to solve all the problems which have arisen as a result of the acute shortage of community facilities, but we hope that it will at least go some way towards providing more much needed care and support for the mentally ill and mentally handicapped.

Finally, I should like to say a brief word about the provision of adult training centres for mentally handicapped people. This is a subject about which there has been a great deal of current interest, as the hon. Lady mentioned in her speech.

This afternoon an all-party meeting of Members of Parliament, parents, and representatives of the National Society for Mentally Handicapped Children has been discussing the provision made for education and training of mentally handicapped young people over 16 years of age.

Most mentally handicapped children leaving special schools who live at home and are unable to enter open or sheltered employment go to adult training centres. In recent years the number of these centres has grown rapidly and nationally the target levels set in the White Paper "Better Services for the Mentally Handicapped" are close to being met. National figures hide local deficiencies, and I am aware that the demand for special facilities for the severely mentally handicapped, who are probably physically handicapped as well or have severe behaviour disorders, is not being met. This is unfortunate, but it is for local authorities to decide their own priorities in their programme for development of their personal social services, although my Department does what it can to influence their selections.

In the past adult training centres gave perhaps undue emphasis to the work and occupation element of their task, but this emphasis is rapidly being changed, with education and social training assuming a much greater importance. Not all 16-year-olds transfer to the ATCs since some local education authorities allow them to remain at school after this age if there are useful educational reasons for them to do so, and provided places are available. For those who do not stay on some authorities arrange courses at further and adult education colleges.

These are problems which are well known, and it is one of the priority tasks of the National Development Group for the Mentally Handicapped which has been set up to advise on the development and implementation of policy to examine them.

The provision of sheltered employment is the responsibility of my right hon. Friend the Secretary of State for Employment, but I know that he wishes to promote sheltered employment where-ever there is adequate evidence of sufficient need. These workshops are run under similar disciplines and conditions as those found in open industry and cater for all kinds of handicapped people, including mentally handicapped and mentally ill people. The work undertaken by trainees in adult training centres does not usually compare with the consistently high standard demanded in open and sheltered employment, but the National Development Group is also considering whether some intermediate provision is necessary.

I hope that these remarks will satisfy the hon. Lady that the Government are very much aware of the need to develop community services for both mentally ill and mentally handicapped people—and not only aware, but actively seeking to bring the necessary improvement about just as fast as we reasonably can. I can assure her that we intend to succeed.

Question put and agreed to.

Adjourned accordingly at one minute past Eleven o'clock.