§ 2.41 p.m.
§ Mr. Robert Boscawen (Wells)
I wish to raise a matter of considerable public importance brought about by the issuing at the beginning of October this year of a discussion document on the future of Mendip Hospital, Wells, a 600-bed, old-established hospital which handles long-stay elderly and mentally infirm patients. I do so because there is a need for a great deal more information locally, and there is still a great lack of knowledge and understanding nationally about our mental health services. Indeed, there is still a need to awaken the public concience about how we as a community should be treating our mentally ill.
The way in which the discussion document was handled has caused much criticism and ill-feeling locally. I do not intend to dwell on the hard things that have been said, some of them by me, although I believe them to be fully justified. I shall make one or two general observations.
There is a need to take extra-special precautions in making proposals for the future care of the mentally ill everywhere. Public attitudes have not caught up with the new concepts of community-oriented care, and there are still substantial doubts about these concepts among highly qualified medical staff. Psychiatric and geriatric medicine are not popular options among the keenest and most able career-minded nurses and doctors. Those who are dedicating themselves to this challenge—we are extremely grateful to those who do—must therefore be kept in as high a state of morale as possible, and questions affecting their personal careers, conditions of work, the localities in which they work, their housing and so on must be handled with care and sensitivity.
People who serve on area health authorities are not generally in the public eye. To be fair to our Somerset Area Health Authority, it was unanimous on the way to handle the document. That is what I have been told by the chairman. However, area health authorities must beware of appearing to be too remote and insensitive to what local people are thinking. They are large employers. In the 1204 Mendip Hospital the authority employs about 600 people, and it is therefore, about the largest employer in the city of Wells. These authorities must remember that they are not directly elected bodies. It is still very much an open question among Members on both sides of the House whether such bodies should be elected or should be made in some way more accountable to the public.
I hope, therefore, that the Somerset Area Health Authority and the other two health authorities involved in the proposals will listen very carefully to all the comments that will be made on the discussion document. I hope they will regard this consultation as the beginning of a long discussion and a prelude to a further and more informed document about mental health care in Somerset and the surrounding area. It would be totally wrong for comments on the first document to be the basis of any final decision.
What strikes me about the document at first sight is that, because of the special circumstances of the three-sector catchment area from which patients come to the Mendip Hospital, this cannot be a one-off decision. How can a fair assessment of the demand for long-stay beds be made for the Wells part of Somerset when one can read in paragraph 4, on page 7 of the document, thatBoth Avon and Wiltshire Area Health Authorities have declared their intention of becoming independent of the services of Mendip Hospital but have at present no firm plans for achieving this."?This should not be, and cannot be, the basis for a one-off decision. A fair assessment can be obtained only by looking at the much broader picture of health care in the three areas. It will be extremely difficult to gain a picture of the likely requirements for mental illness beds in a vacuum. How do the plans for hospital services in Avon. Wiltshire and Somerset tie in with the Resource Allocation Working Party plans for each, for example? That is an important consideration which will have to be taken into account.
We should be extremely sceptical about basing plans entirely on having so many beds for such and such a population. The sizes of patient catchment areas are much more flexible and extended than they were a few years ago. It is not necessarily such a drawback as it was to travel 1205 30 or 40 miles for treatment by a specialist at a certain hospital.
I wish to ask the Minister one question to which I do not expect he can give an immediate reply. It is relevant to the document and the understanding of what is behind it. How are all the costs of treatment and accommodation of the Avon and Bath sector patients debited? Does Somerset bear a major part of other areas' bills? That is an important question which is not answered in the document.
I turn now to the future concept of specialist psychiatric treatment of acute patients in district general hospitals in order to give those patients a pattern of living which more closely resembles normal life and which integrates them with that of shorter-care patients. This is desirable and a matter of great importance. Though it may be somewhat Utopian in present circumstances, we should be looking towards that end. However, there are certain reservations about this in the medical world and the subject requires much study and attention.
I wish to draw the Minister's attention to an article which appeared in the British Medical Journal of 1st May 1972. In the interests of time I shall not quote from it, but it indicates some of the perils of developing a two-tier system of the district general hospitals for acute psychiatric patients and for the long-stay hospitals nearby. Those difficulties should be examined in respect of each area health authority and taken into account when considering the document.
Yet the document bases its present strategy on this and states that the Mendip Hospital may have no rôle to play in the treatment of acute patients. That is a further important matter to be considered. In regard to long-stay patients, there is great scepticism among staff and nurses that bed needs are declining in this area in the way suggested in the document.
I wish to illustrate an area of concern which might suggest that there is substantial under-provision in regard to certain long-stay patients throughout the country. I wish to draw attention to an article in The Guardian of 5th December in which the Lord Harris of Greenwich, 1206 Minister of State, Home Office, was reported as saying:There are now hundreds of mentally disordered people in prison who should be receiving treatment in a psychiatric hospital.Does this indicate a serious under-provision of beds in the psychiatric hospitals? If that is so, it is disturbing and is relevant to the figures showing likely needs of lone-stay patients in psychiatric hospitals in the area.
Nobody I have met among the staff in the Mendip Hospital is other than acutely conscious of the need for constant pressure to find better and more humane ways of caring for and treating the mentally ill. The modern concept of getting away from the large institutionalised hospital atmosphere, must be handled realistically and at a pace that matches the provision of alternative services of high quality. Above all, the approach must be flexible, otherwise the desire to move forward in this difficult field towards more community care will be frustrated. That would be a most unfortunate development when all are trying to treat mentally ill people in as humane a climate as possible.
§ 2.54 p.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Eric Deakins)
I congratulate the hon. Member for Wells (Mr. Boscawen) on securing this opportunity to debate this important matter. I know that he takes a particular interest in health and social services matters, and on this occasion that interest is heightened because of the important contribution the Mendip Hospital, Wells, makes to the level of employment available in the hon. Gentleman's constituency.
The hon. Gentleman has spoken both of the possibility of the eventual closure of the Mendip Hospital and also of the way in which news of this possibility reached his constituents, many of whom are employed at the hospital. It may be helpful and perhaps reassuring to the hon. Gentleman if I set out what action has so far been taken by the Somerset Area Health Authority, which is responsible for the management of the Mendip Hospital, Wells. I would like to lay particular stress on the precise status of the discussions which have taken place and the papers which have been issued for consultation.
1207 The Somerset Area Health Authority at its meeting on 30th September considered a document which examined the future of the Mendip Hospital and the authority resolved that this document should be issued as a discussion paper to all interested organisations and bodies. I would stress here that the authority has not taken a decision to seek the closure of the Mendip Hospital, although such consideration of the needs of the population of Somerset for services for the treatment of mental Iliness that has so far taken place has indicated that it might be open to the authority to take such a decision in 15 years' time.
I cannot, of course, predict what will then be the procedures laid down by the Government of the day when hospital closures are proposed, but at present the procedures are as follows. In general, the initiation of these procedures rests with the appropriate area health authority. If the area health authority decided that a closure or change of use of a hospital was necessary, it would have to institute formal consultations. The procedures require the authority to prepare a consultative document covering such matters as the reasons for its proposals; an evaluation of the possibilities of using the facilities for other purposes, for the disposal of the site; implications for the staff; the relationship between the closure or change of use and other developments and plans; and the transport facilities for those patients who might be affected by the proposals contained in the document. The AHA would invite comments from a wide range of bodies. Those hon. Members whose constituents were affected would also be informed of the proposals.
The area health authority would then seek the community health council's views on the comments it received and on its own observations on those comments. The authority would then review its original proposals in the light of the comments received, and unless there was strong local opposition, it could then implement its original proposals provided that the community health council agreed. The regional health authority and my Department would be informed of the decision.
However, if the community health council objects to the area authority's proposals, it is required to submit to the authority a constructive and detailed 1208 counter-proposal, having full regard to the factors, including restraints on resources, which led the authority to make its original proposal. The matter must then be referred to the regional health authority and if the regional health authority is unable to accept the views of the council and wishes to proceed with the closure or change of use, it falls to my right hon. Friend the Secretary of State to act as an arbiter. However, we have not yet reached this stage and, as I have mentioned earlier, we are not likely to do so until the 1990s.
The hon. Gentleman has spoken of the manner in which news that the future of the Mendip Hospital was under consideration reached his constituents. It is clear that, despite the authority's best intentions, the chain of distribution of the discussion document was such that copies of it reached different people at different times over the period of about a week beginning on 6th October and that some staff interests first learned of the documents' existence in the local Press on 7th October. I very much regret that this happened and that all interests did not receive the discussion document at one and the same time. The hon. Gentleman will know that I attach particular importance to the standards of industrial relations existing in the National Health Service.
Comments on the document have been invited by 31st January 1978, so those bodies and organisations which have been consulted have ample time to formulate their views and put them forward for consideration. I urge everyone to act through these bodies and organisations. The community health councils have been set up to represent the public view and three of these councils have been invited to comment. Staff bodies, too, have been consulted, and the document has been sent to the Somerset area, West Somerset district and Wells sector joint staff consultative committees as well as those trade unions and professional organisations with members employed at Mendip Hospital, but not represented on the committees. Additionally, adjoining area health authorities have been given the opportunity to comment, as have the local authorities concerned and the professional advisory committees.
Therefore, the area health authority has consulted widely and will take full 1209 account of the views presented before deciding what further action to take. No doubt, any proposals that may emerge in due course will also become the subject of consultation.
As the hon. Gentleman pointed out, the Mendip Hospital, Wells, is concerned with the treatment of mental illness. Like many other such hospitals its history stretches back well into the nineteenth century. Our concept and understanding of the needs of the mentally ill has very much changed in the intervening 120 to 130 years. At times the population of the hospital has been as high as 1,000. Today in keeping with the national trend, it is reducing and currently is around 600.
I shall now set out our policy for the provision of services for the treatment of mental illness. I want to make it clear that the Government's policy is not directed towards closing large mental illness hospitals as an aim in itself. Rather, they will be replaced over the next 20 to 30 years by a new pattern of local psychiatric services. This is described in our White Paper "Better Services for the Mentally Ill". Some mental illness hospitals will continue to provide a service for longer than others, and this will depend on local circumstances and the rate of development of alternative facilities. But we look to all regional health authorities to develop a strategy which will, over the next 20 years or so, give people everywhere the benefits of the new pattern of service. The authorities will, of course, do this mainly by redeploying those irreplaceable human resources—doctors and nurses and others—who are today serving the public, in Somerset as elsewhere, and largely in the old patterns of services. But, of course, we do not want to see under-provision for patients who need longterm stay.
The new pattern of psychiatric services will comprise a network of locally based facilities to provide treatment and care according to the varying requirements of those who are mentally ill. It enables the services for these patients to respond effectively to differences of need, and enables people with mental illness to be treated close to their home while maintaining links with family, friends and colleagues. Past experience clearly shows 1210 that lengthy periods spent in mental hospitals isolated from family and friends has made a return to normal life in the community much more difficult—has, indeed, made it impossible in some cases.
The psychiatric unit at the local general hospital will be the centre of specialist psychiatric treatment of mental illness for adults, including the elderly, from its health district. It will provide facilities for treatment on both a day and in-patient basis, and act as the base from which specialist therapeutic teams can provide advice and consultation outside the hospital.
Although the emphasis in future will increasingly be on the provision of treatment in a community or day-hospital setting, hospital in-patient treatment will continue to play an important role. Some people whose mental illnesses can, in the main, be successfully managed in the community, with out-patient or day-patient care, will need to be admitted for short spells to hospital for the treatment of acute episodes, or for more detailed diagnosis and testing. Better treatment and a new awareness of the harm that can be done by long in-patient stays have led psychiatrists to reduce in-patient treatment even if they are still working in distant mental illness hospitals—hence the falling need for beds which the Somerset AHA reports. But how much better if the patient in the community and his doctor remain only a mile apart, not 25 miles!
But I do not want to give the impression that psychiatric units in general hospitals can provide treatment for all the groups of patients hitherto catered for by mental illness hospitals. In the new pattern of locally based services other inpatient facilities are also needed. It is our policy that small units in local hospitals should provide in-patient and day-patient care for elderly severely mentally infirm patients who do not really need all the facilities of our psychiatric hospitals.
At the same time, we recognise the need to provide longer-term in-patient accommodation in each district for those small numbers of younger patients whose mental illnesses do not respond to modern treatment. In the White Paper we suggest that these people may be best cared for in hospital hostels, associated with 1211 but not necessarily part of the main general hospital complex. Regional secure units will also be needed for patients requiring security, though of a degree less than that provided by special hospitals.
Finally, there is a need to develop a high degree of awareness and knowledge about the treatment of mental illness amongst those working in the community—general practitioners, community nurses and social workers—as well as in the community at large, as the hon. Gentleman rightly said. This will ensure that a far greater proportion of mentally disordered people can be treated in the comfort, privacy and security of their own homes. Progress is being made in this direction, too—introduction of the community psychiatric nursing service is valuable also—but we still have a long way to go before a genuinely community-oriented psychiatric service is functioning effectively in every health district in the country.
I must emphasise, therefore, that we would not contemplate agreeing to the closure of a mental illness hospital, if matters do eventually reach the stage of such a proposal coming to the Department, until we were satisfied that adequate alternative facilities offering a high standard of psychiatric care were available in all the districts served by the mental hospital. This will cost money—units will have to be built or adapted to provide the in-patient, day-hospital, daycare and residential accommodation needed, with planning and joint financing between health and local authorities.
Once the new pattern of services is established, I am confident that we shall have a vastly improved psychiatric service which, once established, will cost no more to run than the services which are being replaced—and they will be better, more human in scale, more flexible and closer to the patients' home. They will provide facilities to enable people to be returned to more normal living, where before we could only shut most of them away out of sight.
As I and my colleagues have made clear—in speeches and in reply to Questions in the House—we are determined to make sufficient resources available to enable health authorities to provide these services. The consultative document on priorities for health and personal social 1212 services and "The Way Forward" both make it clear that our policy is to devote an increased proportion of NHS capital and revenue expenditure to improve facilities for the mentally ill. The changes will take time and will require careful planning and full local consultation, especially over the crucial transition period, and Somerset Area Health Authority's action in issuing its own consultation document is to be warmly commended.
Many districts already have psychiatric units in general hospitals--six more were opened last year—and nearly 30 per cent. of all psychiatric admissions in England are now to psychiatric units. But even so, many of the older mental illness hospitals will for some years continue to provide accommodation for the so-called "old long-stay" patients—those patients who have been in hospital for many years and for whom no other accommodation is available. Many of these patients could be better accommodated in facilities in the community, like residential homes, group homes or approved boarding houses, so the rate of progress towards the replacement of the older hospitals will depend to a considerable extent on the build-up of this type of accommodation.
The provision of adequate levels of community facilities, particularly local authority accommodation, is quite crucial to the development of the new pattern of services for the mentally ill. There are two related needs—for social care and for rehabilitation. Various forms of residential accommodation are needed to cater for different degrees of dependency and for various lengths of stay. Day centres need to be provided with a variety of facilities within a single establishment which can be used flexibly to give effective help to each individual.
I know that some doctors and nurses working in services for the mentally ill, and other health and local authority staff involved, feel uncertain about their future at the moment, and may fear upheaval during the change to the new pattern of mental illness services. This is one of the reasons why the Secretary of State set up his working group, which is currently looking at mental hospitals' problems of management and organisation within the psychiatric services. But I want to reassure those who are uncertain about 1213 their future in the psychiatric services that we shall continue to need more staff, not fewer, as the White Paper guidelines on staffing make clear.
I certainly do not want to underestimate the enormous contribution being made by staff working within the limitations imposed by the traditional pattern of mental illness services. They have risen splendidly to the challenge of new techniques, changing work loads and often inadequate and unsuitable facilities. I know that many psychiatric hospitals are continuing to provide an excellent service in very difficult circumstances and that their staff will continue to do so and will respond to the challenge of the transition to the new pattern of services in the same way.
As I have already said, it is not for me, at this point of time, to make any suggestion as to what is the best strategy for the future of the mental illness services in the hon. Gentleman's constituency or in Somerset. It is for everybody who is concerned to discuss this discussion document. This is not something that is being done in a tremendous last-minute hurry. What the discussion document proposes as a possibility is that this hospital should be closed in 1991 or thereafter. May I express the hope that the discussions are constructive and fruitful, and that the local mental illness services build on the strength they have to achieve new strengths?
I have mentioned briefly that we have the NHS planning system under which the regional health authorities produce strategic plans having regard to overall national policies. This is a new development in the history of the National Health Service and I am confident that it will enable us to make better progress in future.
The South Western Regional Health Authority supports the national policy on services for the mentally ill. Its strategic plan covering the 10-year period up to 1986 makes this clear. Its aims include the establishment of health district-based psychiatric services, including day-hospital provision both at the district general hospitals and in community hospitals. As the hon. Gentleman will know, it is intended to develop the Priory Hospital site in Wells as a community hospital 1214 and the area health authority will be planning this.
The hon. Gentleman asked me a specific question about the allocation of the costs of the Mendip Hospital between the three health authorities concerned. I cannot give him information at the moment but I shall write to him with the details.
To summarise, therefore, I can do no more than emphasise that no decisions have been taken on the future of the Mendip Hospital, Wells. It is too early a stage in the consultation process for ministerial involvement, which may even not be necessary at all, and that is why I have purposely avoided any detailed comment this afternoon. I would not, however, wish to close without recording that discussions currently taking place in no way are intended to suggest that the staff at Mendip Hospital are doing other than the best possible job that their surroundings permit. I also recognise that if a large hospital in a predominantly rural community has to close the effect on that community's employment is very significant. It is for this, if for no other reason that consultations on future plans must be particularly thorough.