SCOTLAND (MENTAL DISABILITY SERVICE) (Hansard, 12 March 1980)

§ Mr. Dick Douglas (Dunfermline)

At this early hour of the morning I refer to the phrase of Dylan Thomas on the death of his father. He said: Do not go gentle into that good night, Rage, rage against the passing of the light. I do not wish to debate the whole range of expenditure on the Health Service. I shall refer to a relatively small but important item. I plead in aid the report on services for the elderly with mental disability in Scotland, the Timbury report, which was submitted initially in 1978. I think that it first saw the light of day in mid-1979.

The Minister has sought previously to sustain a case in rather contradictory terms. He has sought to argue that expenditure, in real terms, in 1980–81 will increase. Yet he said that the value of money allocated to the Health Service in total has been eroded by inflation, by under-provision for the Clegg awards and by items such as the increase in value added tax. If that is so, and if expenditure is to be squeezed, we must consider in total terms how priorities will be affected within the service.

I am discussing a Supplementary Estimate that is small in relation to the total expenditure of £15.7 million. However, it must be considered in terms of the way in which it might effect an element of priority within the Health Service—namely, provision for the elderly, and specifically those with mental disability. The Minister must indicate his thinking on the Timbury report.

I turn to the touchstone of the report in 1976, "The Health Service in Scotland: The Way Ahead." Paragraph 4.10 states: In view of the increasing number of old people and the many deficiencies in existing arrangements, the Secretary of State believes 1510 that this sector must be given high priority for Health Service expenditure over the period immediately ahead. I turn to the broad compass of the Tim-bury report. I think that I shall take the House with me when I say that there can be little doubt that the problem of the elderly with mental disability is of major concern in a civilised society.

I have great respect for the Under-Secretary of State for Scotland. I know that he is a humane and understanding man. However, I hope that to me he will not present any market analysis arguments. That will not be good enough. There is no question of standing in the queue and thinking that provision will be made for this severe problem within our society. Some have a sense of shame and others seek to hide the problem.

I have had many private conversations with Professor Timbury during the past few months. His sub-committee reported in July 1978 and indicated both the extent of the problem and the method and approach that could be followed in order to meet the growing demand on society. I am sure that the whole House will wish to express thanks to Professor Timbury and his colleagues for their searching and thoughtful report.

We are dealing with advanced societies in which the proportion of those living longer increases. The mobility of labour in national and international terms places strains on what might be called the extended family. While the population projections of those aged 60 and over in Scotland show a relative stability, at around 19 per cent. or 20 per cent. into the twenty-first century, the breakdown and secular trend of this category can give a better picture of the areas of concern.

As Timbury points out in paragraph 2.16: At the beginning of the 20th century 4.8 per cent. of the Scottish population was age 65 and over: in 1976 the proportion had increased to 13.4 per cent". He adds that during that period: the absolute number in the 65 and over age group had increased more than three-fold from about 215,00 in 1901 to about 698,000 in 1976". The projections indicate a rise of only 5 per cent. in those aged 65 and over to 1991. However, within that broad category, the increase will be among those aged 75 and over; the numbers of those 1511 aged 65–74 being expected to fall by 6 per cent. in 1991. The numbers in the age group 75–84 are expected to rise by 22 per cent. in that period and those over 85 by 49 per cent.

Within that overall picture there are differences in the sex ratio. It is relevant to note that of those aged 75 years and over the present sex ratio of 100 males to 214 females in the 75–84 age group will change in favour of males to 100 to 193 by 1991. However, in the 85 and over age group the ratio of females to 100 males will change from 310 in 1976 to 335 by 1991. So much for the equality of the sexes in life expectancy terms.

I apologise for dealing so much in statistics. I desire to emphasise that we are not dealing with mere statistics and numbers in a report; we are dealing with human beings. Within the broad category of growth in numbers there is a concomitant growth in human problems and suffering.

When we speak of people in these advanced age groups there is little point in suggesting that when they fall mentally or physically ill their immediate families should step in. We cannot rely on such factors as we did in the past. Life expectancy in those days was relatively short. If someone is 75, or in his eighties, his children may be approaching old age. They may also be ill.

I shall turn now to the specific areas of the Timbury report and pose certain questions to the Minister. The report says that the major conclusion arising from the sub-committee's considerations is that much of the accommodation and service provided for the group of persons with a diagnosis of senile or arteriosclerotic dementia is unsuitable for present day requirements". That is a condemnation of all Governments, not just this one.

Of the total of almost 7,000 elderly persons with mental disability who require hospital care, about 3,000 who suffer from dementia are currently in mental illness hospitals in accommodation that is overcrowded and of a quality unsuited to the type of care required. Another group of 750 such persons is inappropriately located in acute or geriatric hospitals, mainly because no places are available in psychiatric hospitals. An estimated 1,250 persons who require considerable medical and nursing care are in homes for the 1512 elderly, provided by local authorities and voluntary organisations. In addition, a sizeable number of elderly people have unmet needs and probably require additional care.

We are seeing a misuse of resources, because society at large has failed to appreciate the pressure of this problem. When we are in our constituencies I am sure that many of us visit local authority old folks homes and geriatric hospitals. There we see people in those establishments who ought not to be there. Society in general must deal pertinently and quickly with the problem.

In examining the 32 recommendations and conclusions of the Timbury report, I am struck by the inadequacy of current provisions. We are dealing with a section of the population who, by their very nature, cannot speak for themselves. I stress to the Minister that there is no point in talking to these people about the ladder or about using resources. By the nature of their illness or disability they are inarticulate. Another voice has to speak for them. Sometimes voluntary organisations do so, but, more appropriately, what can perhaps be called the hard political elements in society must speak for them.

It is not the glamorous area of the medical profession, which hits the headlines with heart and kidney transplants. It is the hard working, physically and mentally demanding area of the profession, which society avoids.

The examination by Timbury shows that there are people in local authority homes who ought not to be there, there are old people in local authority homes who should be under closer medical attention in psychiatric hospitals, and there are a large number of people in the wrong mental illness hospitals.

In paragraph 3.7 the report clearly spells out the requirements and I hope that the Minister will address his mind particularly to this: It says: Having considered four possible solutions for accommodating the elderly with mental disability our view is that only two should be accepted for future planning. The first being the continued provision by local authorities of residential accommodation for the elderly, some of whom, during their period of residence, may become mildly mentally disabled but still be capable of living within the home and not need nursing care. For the elderly with mental 1513 impairment (e.g. severe dementia) which would prevent them looking after themselves or being looked after in their own homes or being admitted to residential accommodation, or which required that they be transferred from residential accommodation, continuing care units should be provided both as replacement and as additional facilities for the psychiatric service. Within the compass of the report it explains exactly what is meant by "continuing care", although there may be modifications in respect of detailed planning.

Do the Government accept the strictures of that paragraph? Within the 10 months, how far has the Minister transmitted the recommendations into the future planning policy of the Health Service? That is a fair question. If the Minister says "We have not done so" the House will be able to make a judgment.

The immediate area of attention is that of identification and assessment. The range of domiciliary services also has to be extended. I hope that I can be contradicted by the Minister when I say that I detect in the body of the Timbury report a lack of liaison between the health services and the social work and housing departments. We have often debated the practicability of splitting housing and social work on a district and council basis. However, the need to plan jointly for the needs of the elderly with mental disability should invoke no petty bureaucratic divisions or empire building. Empire building here should not be tolerated. As Timbury says: closer links between these services and voluntary organisations are essential and different financial arrangements between these services should not be permitted to obstruct reform. That is an important consideration.

I am not in favour of co-ordination purely for its own sake. Co-ordination often involves us in creating another tier of bureaucracy. I do not think that that is what Timbury envisaged. There is a need to ensure effective liaison between a social work department and the health services. I had a pertinent example of the lack of such liaison only today. It is a personal matter and I shall not detain the House with it. It relates to an individual very close to me, who suffers, in my view, from dementia.

1514 The personnel involved in these areas have to possess a greater sense of devotion than is normal in the public service if they are to cater for the needs of this section of the population. As well as the nurses, doctors, administrators and volunteers, the general public need to have a greater understanding of the mental and physical conditions of the elderly. This ought to be an aim of community education. We have just had the Year of the Child. I urge the Minister, if he has not already thought of this, to inaugurate in Scotland a week in every year when attention is focused on the elderly section of the population, particularly those with mental disabilities.

Last but not least I turn to the vexed question of costs. In an earlier reply some allusion was made by the Minister to accepting the general provisions of the report, but it was added that the costs would be astronomical. The ministerial view seems to be that "Timbury is all very well; we should like to carry out its recommendations, but the costs are considerable." The report suggests an urgent start on a major building programme for day hospital places, assessment beds and National Health Service continuing care units for the elderly confused, at a total capital expenditure cost of approximately £44.65 million, mainly in the period 1980–81 to 1984–85, overlapping into the following five years. I have no doubt that these figures have increased since the estimates were made. Perhaps the Minister could tell us at some time—he might write to me—what the situation is in terms of current estimated costs. The important thing is to know how far we have gone in making this urgent start.

The Government are fond of telling us that we should get our priorities right. The Minister lectured us on how we should be like the French, the Germans, the Americans or the Japanese. We are not like them. I could not get the boys in the Rosyth dockyard to do callisthenics in the mornings. I do not think that the Minister could, either. We do not evoke the correct response by a lecture. We must consider the individuals, who cannot, by their very nature, be self-reliant. If we do not cut expenditure in the Health Service we must secure that in this area, where the need is manifest and growing, we cover that need adequately.

1515 Perhaps the most revealing aspect of the Prime Minister's posture was her reinterpretation of the parable of the Good Samaritan. She averred that the Samaritan would not have got very far without the money with which to pay the innkeeper. As a Christian, I reject that interpretation. The innkeeper went much further than mere money service, and so did the Samaritan. If we acknowledge the true meaning of the parable, answering the question "Who is my neighbour?" in relation to the subject raised this evening, society at large has to show mercy and understanding to this section of our population. It is not good enough for the Minister to say that we cannot afford it or that we should allow the market mechanism to work. The cost of that attitude will be unwarranted human suffering—not the less so because it will be relatively silent and non-protesting. The Minister has a report before him pointing the way. I ask him to say how far he is prepared to follow.

§ The Under-Secretary of State for Scotland (Mr. Russell Fairgrieve)

With the leave of the House, I shall reply to this debate on the Consolidated Fund Bill.

I am most grateful to the hon. Member for Dunfermline (Mr. Douglas) for his thoughtful speech. On a previous occasion when you, Mr. Deputy Speaker, had the privilege—or the lack of it—to preside over a similar debate, Scots Members from both sides of the House spoke. The debate had its moments of acrimony. We had one debate, before you took the Chair, when we strayed from the subject and followed devious political routes. Thanks to the thoughtful speech by the hon. Gentleman we may keep on safer ground in this reply. The hon. Member for Fife, Central (Mr. Hamilton), who proposed the previous subject, made his speech, but other hon. Members spoke and I was diverted.

I should like to comment on what the hon. Member for Dunfermline said. I am grateful to him for raising this topic tonight, as it gives me the opportunity to assure him that he is not alone in his concern for the needs of this particularly vulnerable group within our community. We are conscious of the fact that many of the elderly with mental disability are accommodated in unsatisfactory condi- 1516 tions or are in need of a higher level of services than is currently available. We are also aware, as the hon. Gentleman said, that the numbers of people in the upper age groups who are most at risk are increasing rapidly and will continue to increase for some time.

The problem of geriatrics, with or without mental disability, is like a dark cloud overhanging the future of the mental health service. The Government appreciate that health boards and local authorities have a major task before them in securing the improvement and development of services for the elderly in general and for those with mental disability in particular.

When the report on services for the elderly with mental disability in Scotland—the Timbury report, to which the hon. Member referred—was circulated in July last year it was made clear that we were not committed to accepting its recommendations and would take no decisions on it until we had fully considered the comments of the various organisations consulted. In the preface to the report the Secretary of State said that he was not committed to accepting the recommendations in the report and would take no decisions on it until he had considered fully the comments from the various organisations. Although we are still awaiting the views of some of these organisations, I may say that nearly all the comments received so far have supported the conclusions and the main recommendations in the report.

I do not wish at this stage to pre-empt our full consideration of the report's recommendations in the light of the views expressed by Health Service, local authority and other interests, nor do I wish to anticipate what the Government's decisions will be, but we are bound to have regard not only to the importance of the recommendations and the comments that are received but to the wider economic implications of the heavy expenditure that would be involved.

Of course, as the hon. Member for Dunfermline implied, financial resources will be the critical factor in deciding how far and how quickly these recommendations can be implemented. The financial implications are considerable. Capital expenditure would be about £80 million, spread between the health boards and 1517 the local authorities over the next six or seven years and additional revenue expenditure would eventually amount to about £30 million a year at current price levels. When one considers the total spending of about £900 million on health in Scotland and puts the figures into perspective one sees that we are dealing with figures of a fair size.

There is perhaps no need for me to reiterate the Government's determination to restore order to our economy and, as an essential means to this end, to reduce the overall level of public expenditure. We have also stressed how important it is that services for the most vulnerable groups within the community should be protected and should continue to develop as far as possible.

The elderly with mental disability form one of several such groups, as hon. Members well know. The hon. Member for Dunfermline pointed out that such people do not have the voice or the strength to make their predicament known, and it is up to others to bring to our notice the problems and disadvantages that they suffer. It is simply not possible for the Government to provide additional finance for the rapid development of all the various services for these groups, much as we would all wish that this could be done.

The provision and development of these services is the responsibility of health boards and local authorities and I am sure that whatever difficulties they have to overcome they will do their best within the available resources to give priority where the need is greatest.

There were certain other points that the hon. Member made in his speech. I accept the inadequacy of current provisions. The hon. Member is right to say that this is an unglamorous area, in which we have difficulty in recruiting nursing and other staff. There is a need for residential accommodation, as it is present thinking in health and social work circles that wherever possible such people should be treated within the community.

1518 The hon. Member mentioned the possibility of continuing care units. The liaison with which we are dealing in the Health Services Bill, which is at present going through its Committee stage, tries to achieve a closer working in joint or support financing between social work departments and health boards in order to bring this grey area of care more to the attention of all concerned.

The hon. Member for Dunfermline mentioned possibilities on the lines of the Year of the Child. This is a year for the disabled. The hon. Gentleman is right to suggest that at some time there should be a year for the elderly.

I have given the cost in local government and Health Service expenditure. I do not wish to refer to the acrimony of the previous debate. As the hon. Gentleman knows, the Government do not have the money available for what they would like to achieve in this sphere. There would have to be an increase in taxes or a transfer of resources. Alternatively, our country has to become wealthier.

The hon. Gentleman asks how far the Government have proceeded. We have not proceeded yet to implement the Tim-bury report. Comments have been received. It is the wish of the Government as, I believe, of the previous Government, to implement the conclusions of the report as far as possible within the sources available.